Miscellaneous.

REMARKS ON THE CAUSES AND MORBID ANATOMY OF MENTAL DISEASES.

BY JOHN WEBSTER, M.D., F.R.S., &c.*

(From the LANCET.)

THE author commenced his paper by observing, that having had two of his communications already published in the 26th and 28th volumes of the Society's Transactions, on the Statistics and Pathology of Mental Diseases, he presented the present as a further exposition of the subjects then discussed. He then stated, in illustration of the comparative frequency of madness in the two sexes, that out of 1798 lunatics admitted into Bethlem Hospital, during six years, ending the 31st of December last, 1094 were females, and only 704 male patients. He next alluded to the causes apparently producing insanity, which he divided into moral and physical, besides hereditary tendency to mental disease. Of the male lunatics, nearly one half, or 346, became mad from moral causes; whilst the proportion of females was not quite so considerable, being 489 of the entire number. By physical causes, less than one-fourth of the male lunatics, or 156, became insane; whereas, amongst the female patients, the proportion was rather larger, being 282. Hence, speaking generally, moral causes produced half the total cases; but physical causes only one-fourth. The principal moral influence which occasioned insanity amongst males was reverse of fortune, whereby 86 examples are recorded. Next, anxiety, which furnished 69 instances; then religion, giving 45 cases; lastly, love, which caused the loss of reason in 18 men. Amongst female lunatics, anxiety was the most frequent moral cause, producing 79 instances out of the 489 patients classed under the above category; whilst 69 cases arose from religion; 62 from the loss of relatives; and 57 from the more powerful influence of Cupid's tender passion upon the susceptible feelings of women. Fright caused insanity in 50 cases; reverse of fortune in 49; whereas, amongst men, as already stated, the same cause produced nearly treble that amount, speaking comparatively. In regard to physical causes, of the 156 male lunatics so affected, 80 originated from intemperance; and of the 282 female lunatics, similarly classified, 117 arose from puerperal disease. Other physical causes were subsequently mentioned by the author, before passing to the examination of hereditary tendency to mental complaints. Of 704 male lunatics previously enumerated, 219, or 31.10 per cent., had hereditary tendency to mania; but of the 1094 female insane patients, the proportion was larger-namely, 390, or 37.47 per cent. The author, amongst other remarks respecting the influence of hereditary tendency in producing mental disease, said, such an important fact, wherever it exists, should be always well considered by parties forming matrimonial engagements; especially, when both families are unfortunately so tainted. He next adverted to the age at which insanity is most likely to supervene. In males, he stated the most susceptible time of life was from 30 to 40; but in females it was earlier, being from 20 to 30. The author subsequently noticed the two sections of psychological physicians now dividing the profession--namely, the "vitalists" and the "anatomists," of which latter body he is himself a disciple, since he considers their doctrine the most rational, and in a greater degree consistent with the

Read before the Royal Medical and Chirurgical Society, Tuesday, May 8, 1849, Dr. Addison, president.

present advanced state of pathological knowledge respecting mental diseases. The author afterwards gave a synopsis of sixty-seven dissections made at Bethlem Hospital, of which the following is a summary of the diseased appearances observed in the brain and membranes. In 53 cases, effusion of water had taken place in the ventricles; in 53 cases, also, there was infiltration of the pia mater; in 38, turgidity of the cerebral bloodvessels; in 30, the arachnoid membrane was thickened and opaque; in 26, the colour of the brain was altered from its natural tint; in 15, there was an effusion of blood within the skull, besides other alterations of structure, as mentioned by the author. The organs of the chest were likewise more or less diseased in as many as 62 of the patients; whilst in 30, morbid changes were likewise noticed in the abdominal viscera; so much so, indeed, was this the case, that the immediate cause of death, in a number of the insane patients referred to in the present communication, was apparently disease in these parts; but more especially, affections of the organs of respiration. Dr. Webster then alluded to the long period during which some of the lunatics had laboured under mental aberration, particularly females, one female lunatic having constantly resided in the incurable ward at Bethlem Hospital for upwards of half a century, or actually fifty-four years; thereby showing, that the loss of reason is sometimes not incompatible with longevity. After again referring to the deductions contained in his previous papers communicated to the Society, the author concluded by remarking, that the facts and statements now brought forward, fully confirmed his former observations, and he hoped they might prove useful to students of medical psychology.

Mr. SOLLY, whilst he complimented Dr. Webster on the value of his paper, could not help regretting that no account had been given of the appearance of the cortical substance of the brain-that portion of the cerebral mass which was essentially connected with the intellectual manifestations. He thought we were in error in our dissections of the brain, to view the organ as one whole; but that we should, as we did with the contents of the chest or abdomen, examine and describe each individual organ and part. Dr. Bright had referred to the colour of the cortical substance of the brain in some dissections of insane patients; and he (Mr. Solly), in examinations at Hanwell and elsewhere, had, as a general rule, found this portion of the brain higher coloured when excitement preceded death, but pale if the insanity had been of long continuance, and without excitement. He (Mr. Solly) had called this portion of the brain the hemispherical ganglia," for want of a better term, and regarded its appearance after death as most essential to be mentioned in cases of insanity. One interesting fact was mentioned in the paper, and that was, the frequency with which the pia mater and arachnoid were found injected; these only acted in insanity, of course, by influencing the brain in their immediate neighbourhood. He therefore assumed that the brain so situated was affected, as this condition of the membranes was not sufficient to produce the insanity.

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Dr. A. J. SUTHERLAND was sure that the Society must feel much indebted to Dr. Webster for bringing under their notice much important information relative to the causes and the pathology of insanity. He did not know any subject so difficult as that which Dr. Webster had chosen. The causes of insanity were in many cases difficult to be ascertained; the friends themselves were frequently mistaken as to the real cause of the illness; and it was only now and then that we were able to correct the mistakes of the friends, from the symptoms of the case. But again there were these difficulties which beset us when we investigate the causes of the disease: what obtains in hospitals, such as Bethlem and St. Luke's, did

not always obtain in other places; what prevailed among the patients of one class of society, did not equally prevail among those of another. Thus, the hereditary predisposition to insanity was, as stated in the paper, onethird; as stated by others, one-sixth among the lower classes, whereas it was as much as one-half among the higher. With respect, also, to sex, a greater proportion of females in the lower class, and a greater proportion of males in the higher classes of society, become insane. Therefore we were likely to be misled, if we took any particular class of patients as examples of what prevailed generally; for not only were there differences in the proportion, but there were differences in the species of insanity, in different places. Thus, in the agricultural districts of this country, the proportion of the insane to the sane, was as 1 to 800; while in the manufacturing districts it was as 1 to 1200. But not only the occupation, but differences in climate and diet appeared to have an influence in the production of this or that species of nervous disorder. Dementia and imbecility were supposed to be common in marshy countries; hypochondriasis abounded in Iceland; and in the Western Islands of Scotland, the nostalgia of the Swiss, the cretinism of the Vallais, and the pellagra of Lombardy, were also familiar instances. He differed in some respects with Dr. Webster, as to what he had observed relative to the pathology of insanity, not, he meant, with regard to post-mortem examinations, which formed but a small part of the pathology of any disease, but with regard to pathology in its widest sense, drawn from the symptoms during life, as well as the appearances after death,-drawn from the causes, even from the treatment of the disease. He thought that Dr. Webster had done well in not considering the pathology of insanity apart from its causes; for as there were distinct causes, moral and physical, so there were distinct origins of the disease. The disorder might take its rise primarily from the nervous centres, or the different organs of the body. The liver, the uterus, and the stomach, might affect the brain, and insanity might be the consequence. Insanity, therefore, might be said in one sense to be idiopathic; in another sense, symptomatic; but whether the one or the other, it was the seat of the intellect and the affections which was deranged; and therefore we looked with peculiar interest to the cerebrum, to throw some light upon these difficult investigations. With respect to post-mortem examinations, his experience corresponded with the facts recorded in the paper. He had never found the results of acute inflammation in the brains of lunatics, and what Mr. Solly had stated with regard to the cortical structure was certainly correct-viz., that there is, for the most part, a state of hyperæmia in acute cases, a state of atrophy in chronic cases; there was also a disposition to venous congestion in some brains, to active congestion in others; but the effusion into the sub-arachnoid tissue, and into the ventricles spoken of in the paper, and so frequently found in these cases, was rather the effect than the cause of the disease; in the acute stage it was probably the result of venous congestion, and in the chronic stage it was due to atrophy of the brain, just as the spinal marrow becomes atrophied in tabes dorsalis. But he apprehended there were few who would think that what we saw after death was all that had occurred during the progress of the disease, and therefore the pathologist would be inclined to apply to the symptoms which he had seen during life, and to the analysis of the different fluids of the body, to help him in his investigations. With respect to the former, the symptoms which the intellectual faculties furnished were those of undue activity on the one hand, and of extreme dulness on the other, while the physical symptoms were generally those of irritation, sometimes of congestion, never of acute inflammation. From the analysis of the blood of insane patients, we knew that there was no excess of fibrin, while from

the analysis of the urine we obtained sometimes a plus quantity, sometimes a minus quantity of the phosphates, thus confirming, as far as it went, the evidence which we derived from other sources. With respect to the analysis of nervous matter, L'Héritié had shown that there was a minus quantity of phosphorus in the brains of idiots; and Couerbe asserted that he had found a plus quantity of phosphorus in the brains of maniacs. But not only was it a matter of importance for us to ascertain the quality of the blood, but it was also requisite to estimate the quantity which circulated in the brain. Not only had we examples of insanity from the poison of other diseases from bad blood, but we had examples from local congestion of the brain, and from anæmia. Many patients were admitted into St. Luke's, whose disease had originated in low diet and starvation, in whose brains might be supposed to have commenced that process of oxida tion which Liebig called "eremacausis." But we should also feel inclined to examine into the condition of that subtle fluid, the nervous force, which ministered to those influences by which the mind manifested its ideas, and which, when disordered, counteracted and obscured its development. These were the heads of some of those subjects which he trusted at no distant period might throw light upon the pathology of insanity.

Dr. WEBSTER said, that in reference to Mr. Solly's remarks respecting the morbid changes in the cortical substance not being sufficiently dis tinguished from the appearances observed in the medullary; this arose from the fact, that only a summary, not the particulars, of the various autopsies were detailed to the Society. Had the synopsis been read entirely, the points adverted to by that gentleman would have been explained. All the morbid changes noticed were accurately mentioned, and when it was remembered that most of the dissections had been made by so distinguished an anatomist and physiologist as Mr. Lawrence, this must be a sufficient guarantee of their value and accuracy. Dr. Sutherland had alluded to the influence which climate, geographical position, and the civil condition of individuals exerted in the production of insanity. In many of these remarks he fully concurred, and would even affirm that the religious, political, and social status of the inhabitants in particular countries, materially affected the results produced by ordinary exciting causes. For instance, insanity is a much more common disease in cold climates than in temperate or warm countries. In Sweden and Norway a larger proportion of the inhabitants become mad than in any other part of Europe. The disease is more frequent in North Germany than in the southern part of that empire. Mania prevails more in Belgium than France, in the northern departments of which latter country it is met with in a higher ratio than amongst the natives of the south. In Spain the disease is less common than in France; whilst in Northern Italy, insanity is reported to be twice as common as in the southern part of the Italian peninsula. Again, on the southern shores of the Mediterranean, the disease is still less frequent -as in Egypt, Syria, &c.; and in Arabia, mania is so rare, that it is seldom observed; indeed, a chief physician to the great hospital at Alexandria has stated, that during ten years he had only met with one insane Arab, notwithstanding the number of Arabians in Egypt, and the large population of that city. To show the influence which agitation and great mental excitement produce amongst the inhabitants of a country in reference to the disease under discussion, he (Dr. Webster) might mention that maduess was frequent amongst the Crusaders, whilst the disastrous effects of this enthusiasm continued long afterwards. During the reformation in Ger many, the Low Countries, and in Britain, insanity became common; likewise during the civil wars of England, and the domination of puritanism under the Long Parliament and Cromwell. The first revolution in France

caused many cases of insanity, and when Napoleon upset dynasties, made kings, queens, and titled personages, almost by wholesale, imaginary sovereigns and princes were numerous in the asylums of France and Germany, of which Pinel gives examples, and tells us that in Bicêtre there were, at the same time, three Louis-the-Sixteenth maniacs under treatment. As stated in the paper, the recent revolution in Paris had produced most melancholy results on the minds of many individuals of that formerly gay capital. He (Dr. Webster) could say so from his own personal observation, verified by the experience of physicians attached to lunatic establishments, private as well as public, of that country, where political excitement, clubbism, and the late bouleversement of public institutions and private fortunes, have occasioned very lamentable consequences. Dr. Sutherland remarked, although more females became insane in the lower ranks of society than men of the same class, still, amongst the higher grades of people in Great Britain, more men than women were affected with madness. This was certainly true to some extent, especially as hereditary tendency to mania appears more prevalent in the upper than the lower classes, and purity of blood, as it is erroneously called, often influences matrimonial engagements to a greater extent than amongst the commonalty. This was formerly well exemplified amongst the old noblesse of France, the clans of Scotland, and the sangre azul, or blue blood of the Spanish grandezza, in all of whom mental and physical qualities were then transmitted to offspring in greater purity, whether for good or evil, than amongst the more mixed blood of common people. Notwithstanding the facts alluded to by Dr. Sutherland, insanity was generally more common in women than men throughout England, as shown by the recent report of the Lunacy Commissioners, and as the patients treated at Bethlem Hospital were not paupers, but often persons of education, such as governesses, clergymen, merchants, and many others of a similar situation in life, but broken down by disease as well as poverty; and as they come from all parts of the country, are not confined to the metropolis, but often the reverse, the results thus met with respecting the two sexes, therefore, constitute a good criterion, and support the conclusions stated in the present paper. Religious persuasion exerts considerable influence in this malady; at least, it seems to be more common among Protestants than Catholics, and prevails to a greater extent in converts and proselytes, than in persons of confirmed steady faith, whilst it is oftener met with in countries where religious controversies are common, than elsewhere. Many other points might also be mentioned, bearing upon the question of insanity; but although interesting, he would not trespass upon the time of the fellows further than to observe, that the chemical investigations alluded to by Dr. Sutherland were most important, and deserved the attention of practitioners: that physician had already done much to elucidate this subject, and he hoped soon to see more accomplished in the above branch of medical science, as applied to mania. The field was both rich and extensive, and now that the profession generally had begun to study mental diseases, their nature and treatment, in the way they deserved, much benefit would thereby accrue, as well to medical men as, through them, to the community.

Mr. STREETER Considered the Society deeply indebted to Dr. Webster for the large amount of information, drawn from the records of Bethlem Hospital, which he had placed before its fellows. No one had taken so much pains as Dr. Webster to make the experience of that institution available to the profession; and his papers certainly afforded valuable materials for the study of insanity. When, however, Dr. Webster called upon medical men to apply themselves to the study of this disease, he begged to inquire where the facilities for following out that study existed? They were cer