Again, taking only cases of general paralysis, Professor Westphal holds that in by far the greater number of brains of insane persons dying in an advanced stage, morbid appearances similar to those which he has described in Griesinger's "Archiv. I.," etc., can be traced; the morbid appearances of the cord occurring more constantly than those of the brain.
Dr. Major found that of the post-mortems of paralytics, all displayed appreciable morbid lesions, although in five per cent. of cases they were not typical of general paralysis.
Then coming definitely to the question whether these pathologists have, to any considerable extent, been able to connect the morbid appearances found in cases of insanity with the symptoms, including motor troubles, Dr. Major says that at present he cannot; and Professor Westphal says that he regards "the connection of morbid symptoms with the changes found after death as exceedingly uncertain and doubtful."
I should observe that Dr. Major grounds his statements upon his own recent experience and observation at Wakefield, and that he is not disputing the greater preference shown by certain lesions in general paralysis for particular localities; but only that he does not yet see his way to connect them with the abnormal symptoms present during life. The researches carried on by Dr. Mickle, contributed to our Journal (January, 1876), and those of Dr. Crichton Browne, published with illustrations in the "West Riding Reports," must be regarded along with M. Voisin's large work and Hitzig's article in Ziemssen's "Cyclopædia," as placing before us whatever evidence can be adduced on the relations between the pathology of general paralysis and cerebral physiology. Hitzig, who from his investigations into the cerebral motor centres, and his position in an asylum for the insane, ought to be qualified to judge, surmises that those localities of the brain by the electrical irritation of which in animals he produced epileptiform attacks bearing the closest resemblance to the attacks of paralytics, are affected in general paralysis. He thinks, moreover, that as destruction of these cortical spots causes disturbance of motion, resembling the symptoms pathognomonic of grey degeneration of the posterior columns observed in general paralysis, there is an added reason for assuming this connection.
Dr. Mickle in his recent excellent work on general paralysis has exercised much cautious discrimination in admitting the relation between the symptoms and the alleged psycho-motor centres, and while his researches in a rich field of observation at the Grove Hall Asylum lead him to find some cerebral lesion in every case, especially in the fronto-parietal region, he cautions against the "too ready indictment of motor centres in the cerebral cortex as answerable for the most frequent and characteristic motor impairment, that of the lips, tongue, face, and articulatory organs generally;" fully believing, however, that in the production of these symptoms the cortical lesion is at the very least an important factor. "Whether the principal mental symptoms can be entirely referred," he says, "to the organic changes in certain frontal (and parietal) convolutions—the motor to those of the so-called cortical motor zone—the sensory to those of certain portions of the temporo-sphenoidal and parietal—must remain a matter of question," while in regard to the convulsive attacks, Dr. Mickle has in some cases been "unable to trace a harmony between these and the results of physiological experiment; in other cases they have seemed to harmonize fairly."[310] Dr. Mickle informs me that in the insane other than general paralytics, he has in the majority found some lesion in the brain and membranes.[311]
These results of research in cerebro-mental pathological anatomy and physiology may not seem, when placed side by side with the sanguine opinions of Schroeder van der Kolk and Parchappe, to present so triumphant a proof of progress and solid gain as might be desired or expected, and much, we must admit, has to be done before Pinel's question can be answered with the fulness we should wish. Nevertheless the advance is very considerable, and the best proof of the accumulating knowledge of the morbid histology of the brain and cord in the insane will, I think, be given this week by the collection of microscopical preparations of Gudden, Holler, etc., brought together by the untiring energy of Dr. Savage, including his own at Bethlem Hospital. I have but to point out how impossible such an exhibition would have been forty years ago to give significance to the contrast between 1841 and 1881; thanks to those who, although they may still often see as "through a glass darkly," have so wonderfully advanced the application of microscopic examination to the tissue of the brain, and prepared such beautiful sections of diseased brain and cord.
Another proof of progress might have been given, had time allowed of a reference to what has been done in the study of the brains of idiots, both morphologically and histologically, by Mierzejewski, Luys, and others, these results being sufficient to prove, had we no other evidence, the fundamental truth of cerebro-mental pathology—the dependence of healthy mind on healthy brain.
We are surely justified in expecting that by a prolonged examination of every part of the brain structure, and the notation of the mental symptoms, we shall arrive in future at more definite results; that the locality of special disorders will be discovered, and that the correlation of morbid mental and diseased cerebral states will become more and more complete, that the scientific classification of mental maladies may be one day based upon pathological as well as clinical knowledge, and psychology be founded, in part at least, upon our acquaintance with the functions of the brain. Let us hope, also, even though it be a hope in the sense rather of desire than of expectation, that by these discoveries the successful treatment of mental disorders may be proportionately advanced.
I would now turn to the very important question whether the treatment of the insane has advanced since 1841?