Chapters in the History of the Insane in the British Isles

by Daniel Hack Tuke

No one will deny that the relations of mind and brain, physiologically and pathologically considered, have in our own country been ably handled by Dr. Maudsley. Those who most widely differ from some of his conclusions will acknowledge this ability, and that his works are expressed in language which, with this author, is certainly not employed to conceal his thoughts. To trace the influence of these writings, and those of Herbert Spencer, Bain, and others of the same school, on the current belief of psychologists would, however, carry me far beyond the legitimate limits of an address, but I may be allowed to observe that here, as elsewhere, we must not confound clearly ascertained facts in biology and mental evolution with the theories which are elaborated from them. The former will remain; the latter may prove perishable hay and stubble, and when we overlook or ignore this distinction, it must be admitted that we expose ourselves to the just rebuke of the celebrated Professor of Berlin when he protests against "the attempts that are made to proclaim the problems of research as actual facts, the opinion of scientists as established science, and thereby to put in a false light before the eyes of the less informed masses, not merely the methods of science, but also its whole position in regard to the intellectual life of men and nations." He is surely right when he insists that if we explain attraction and repulsion as exhibitions of mind, we simply throw Psyche out of the window and Psyche ceases to be Psyche;[307] and when, allowing that it is easy to say that a cell consists of minute particles, and these we call plastidules, that plastidules are composed of carbon and hydrogen, oxygen, nitrogen, and are endued with a special soul, which soul is the product of some of the forces which the chemical atom possesses, he affirms that this is one of those positions which is still unapproachable, adding, "I feel like a sailor who puts forth into an abyss, the extent of which he cannot see;" and, again, "I must enter my decided protest against the attempt to make a premature extension of our doctrine in this manner—never ceasing to repeat a hundred-fold a hundred times, 'Do not take this for established truth.'"[308]

We all believe in cerebral development according to what we call natural laws or causes, and in the parallel phenomena of mind; as also in the arrested and morbid action of brain-power by infractions of laws or by causes no less natural. In this sense we are all evolutionists. The differences of opinion arise when the ultimate relations of matter and mind are discussed, and when a designing force at the back of these laws is debated. But these questions in their relation to mental evolution, as to evolution in general, do not enter the domain of practical science, and are not affected by the degree of remoteness, according to our human reckoning, of this force or "Ultimate Power."

It will not be denied that at least the foundations of the pathology of insanity have been more securely laid in cerebral physiology during the last forty years, in spite of the fact that the relation of the minute structure of the brain to its functions, and the nature of the force in operation, still elude our grasp. The so-called disorders of the mind having been brought within the range of the pathologist, what can he tell us now of the post-mortem lesions of the insane? Can he give a satisfactory reply to the question asked by Pinel in his day, "Is it possible to establish any relation between the physical appearances manifested after death, and the lesions of intellectual function observed during life?"[309]

It is a little more than forty years since Lélut published his work entitled "The Value of Cerebral Alterations in Acute Delirium and Insanity," and Parchappe his "Recherches," to be followed by other works containing valuable contributions to the pathological anatomy of mental disease. To attempt to enumerate the contributions to this department abroad and at home would be simply impossible on the present occasion. I cannot, however, omit to notice how early Dr. Bucknill was in the field, as his laborious examination of a number of brains of the insane to determine the amount of cerebral atrophy and the specific gravity, bear witness, as also his demonstration of the changes which take place, not only in the brain and its membranes, but in the cord, in general paralysis; these observations, along with those of Dr. Boyd, having been fully confirmed by subsequent observers.

I recall here, with interest, a visit I paid eight and twenty years ago to Schroeder van der Kolk at Utrecht, whom I found full of enthusiasm (although racked at the time with neuralgia) in the midst of his microscopical sections. And this enthusiasm I cannot but suspect insensibly coloured what he saw in the brains and cords of the insane, or he would hardly have said, as he did say, that he had never failed during a quarter of a century to find a satisfactory explanation after death of the morbid mental phenomena observed during life.

It must not, however, be forgotten that Parchappe, just forty years ago, was able to speak as strongly in regard to the brains of general paralytics; and that of others he said that it would be nearer the truth to assert that you can, than that you cannot, distinguish between a sane and an insane brain.

Since that period microscopes of higher power have been sedulously employed by European and American histologists, and in our country the example set by Lockhart Clarke has been followed by many able and successful investigators. I had intended to enumerate in some detail the gains of pathological anatomy in cerebro-mental diseases, and to endeavour to apportion to those who have cultivated this field of research their respective merits; but I find it better to consider what is the practical result of these researches. I may, however, so far depart from this course as to mention the memoirs of Dr. J. B. Tuke in the Edinburgh Medical Journal of 1868 and 1869, and elsewhere, on account of their importance in the history of the morbid histology of insanity.

Returning to the practical question of the knowledge now possessed by the cerebral pathologist, I will put into the witness box Professor Westphal and Dr. Herbert Major, as having enjoyed and utilized large opportunities for making microscopic and macroscopic examinations of the insane, and not being hasty—some think the former too slow—to admit the presence of distinctive lesions.

Now, Professor Westphal informs me that he is unable to trace, in the majority of post-mortems of the insane who have not suffered from general paralysis, any morbid appearance of the brain or its membranes, either with the naked eye or the microscope. He maintains that it would be impossible to designate amongst a hundred miscellaneous brains those which have belonged to insane persons, if the cases of general paralysis had been eliminated.

Dr. Major speaks guardedly; but inclines to think that, even putting aside general paralytics, the sane may be generally distinguished from the insane brain. His experience at Wakefield shows that in only seventeen per cent. of the autopsies (excluding general paralysis) the brain showed no decided morbid change. "It must be always remembered," Dr. Major writes, "that the difficulty is not to distinguish between the insane brain on the one hand and a perfectly healthy and vigorous sane brain on the other—the difference between these two extremes is, in my own experience, most striking and startling. The difficulty is to distinguish between the insane brain and that of an individual sane, but in whom the brain is (as in time it may be) anæmic, wasted, or even with tracts of softening. Still," he adds, "I think, generally speaking, the sane organ may be distinguished from the insane, the decision turning largely on the degree of the degenerative or other morbid change."