MENTAL BESETMENTS.

Mental besetments or obsessions will be considered in their general aspects, position, and relations. It is not intended to make elaborate clinical description of their various forms. To systemise, and to make the scope of what follows clear at a glance, the subject will be divided under several heads:—

1. A slight outline of besetments of mind or obsessions will be drawn.

2. Their psychological and clinical position will be briefly examined in the division of them by the writer.

3. Next their general characters will be noticed, and

4. Fourthly, the necessity of extricating them, by differential distinction, from conditions with which they have been confounded.

5. Together we take (a) their gradual development in some cases into special mental disturbance, and even into actual insanity; and (b) their desperately dangerous and injurious type in some examples, and the graded scale between these and the trivial.

6. Their relation to phenomena in primitive man, and in savages, and to conditions in ordinary forms of paranoia.

7. Their nosological position, alliances, and congeners.

8. Cases illustrating several of the foregoing departments of the study of besetment.

9. The clinical aspects of obsessions in their several degrees. and instead of giving a long clinical account of the many forms of obsession I will end by reproducing a description—written, apparently, in the mental life-blood of the sufferer, a master of English—the earliest full description, and the best one that has yet appeared of certain forms of obsession.

“Clearer conceptions of these matters would be reached if, instead of thinking in abstract terms, the physiological processes concerned were brought into the foreground.” Prom this counsel which Mr. Spencer gave—counsel which disputants have been slow to follow—towards the end of the unsatisfactory controversy which succeeded the translation into English of Weismann's essays, we shall depart as slightly as possible. Yet at the outset we must deal with “abstract terms,” in attempting to define the real issue which Weismann has raised; even if, in so dealing with them, I do but demonstrate how much wiser it would be to avoid them.

Mr. Briscoe gave an account of hereditary influences affecting reproductive processes, entering into details relative to syphilis and temperaments. He held that deviation from a normal standard of mind and body must indirectly affect the reproductive processes. He thereafter traced the life history of a typical neurotic in a series of clinical pictures. Mr. Briscoe illustrated his paper by photographs of a skull which he had brought from East Africa. The skull was also submitted for examination, and was described as having belonged to a child six years of age, to be generally five-eighths of an inch thick, with completely obliterated sutures. The whole was porous (osteoporosis), and the new cancellous tissue of a columnar appearance, and superimposed upon the original bone. Mr. Briscoe was of opinion that it might be useful to compare such a cranium with deformed palates in relation to brain growth. The heredity of direct mental weakness was then discussed, and Mr. Briscoe was of opinion that 90 per cent. of the insane have a heredity of insanity.

No Disproportionate Increase of Insanity.

The increase of the total living insane in England and Wales during the intercensal period 1881–91 was 15·24 per cent., while the corresponding increase of population was only 11·7.

It is scarcely 20 years since those interested in asylum administration in Scotland began to realise that the interests of the sick and infirm were not so adequately provided for in asylum construction as the requirements of such patients demanded. The desire to improve the efficiency of asylums by providing ampler accommodation for the treatment of that class of patients gradually extended itself so as to include within its scope the treatment of the acutely insane in combination with the sick and infirm, that is, all the inmates of asylums who especially require the services of the physician and the nurse. This idea again expanded itself until a rearrangement of the whole asylum population into two main portions was proposed. The smaller portion was to consist of the newly-admitted cases, of cases requiring special medical attention for any reason, and of the sick and infirm cases. The larger portion was to consist of the quieter chronic and industrious cases for whom the same active medical and nursing supervision was unnecessary. This, which may be called the hospital movement in the Scottish Asylums, has now attained practical expression, and has with considerable variety certainly, yet with conspicuous uniformity in its main principles, been adopted in upwards of 50 per cent. of the public asylums of the country.

My object in this paper is to give a brief note of a trial which has recently been made in the Fife Asylum, in the way of introducing female nursing in the male sick-room. Nursing is peculiarly woman's province; and it has, I believe, often been felt that it would be a great advantage if female care could be more freely utilised in the management of male insane patients, or at least of those of them who are suffering from special bodily disease in addition to the mental symptoms. The main objections to the step have hitherto been: (1) that some of the habits and peculiarities of the male insane may make it unfit or undesirable to have them under female care; and (2) that in many asylums the structural arrangement makes it difficult or impossible to bring the male sick-room under systematic supervision by the female staff. Lately it was necessary to build a large addition to the Fife Asylum; and advantage was taken of this opportunity to get rid of the second objection mentioned. The new building is a hospital block, and is intended to receive recent admissions, cases requiring special observation on account of their mental state, and cases of bodily illness. Each side (male and female) is divided into three sections: 1st, sickroom proper (for cases of bodily illness); 2nd, special observation ward (intended for new cases, and cases needing continuous supervision on account of suicidal or other dangerous tendency); and 3rd, general observation ward. There are the usual dining-hall, kitchen, and administrative rooms in the centre of the building. The male and female sick-rooms are placed next to the administrative portion, one on each side; and as the doors here are unlocked during the day, with free communication by the corridor, the male sick-room is easily reached from the female side, and is administered by the matron, the head nurse (who has charge of both sick-rooms), and two junior nurses. Each sick-room communicates with a special observation dormitory, beyond which again is the special observation day-room. This dormitory is empty during the day, but receives at night the cases which require continuous supervision on account of suicidal tendency, and which come to it direct from the special observation day-room. On the male side the door between the sick-room and the observation dormitory is kept locked during the day; and there is thus no direct communication between the sick-room and those parts of the male side which are under the charge of attendants, except by the general corridor. When the Medical Officer makes the evening visit, this door is unlocked, and the sick-room and observation dormitory are thrown into one and come under the charge of a male attendant, who is on duty during the whole night, while the nurses return to the female side of the building. This plan was followed because our numbers are too small to require separate attendance in the two rooms; and in this way the sick-room is under female care during the day, but is supervised at night by the male staff.∗

In the year 1879 Dr. Urquhart and Mr. W. S. Tuke each wrote an account in this Journal∗ of his visit to the asylum at Cairo, which was then, and is now, the only institution for the treatment of the insane in Egypt. Their impressions were most unfavourable. Dr. Urquhart says, “there is “in Cairo” no more melancholy and degrading fact than the common madhouse.” “The Conolly of Egypt has still his work to do.” “The whole place is so utterly beyond the ken of civilisation that it remains as hideous a blot on the earth's surface as is to be found in the Dark Continent.” Mr. Tuke said:—“The place looked intensely squalid;” “with regard to the means employed in Egypt for the cure of insanity, I find that bleeding is the chief therapeutic remedy.” No statistics could be obtained by either visitor. Since then the institution has been removed from its old site in a suburb of the city out to a palace and stable of the late Khedive Ismail at Abbasiyeh, about three miles north of Cairo. The weakness for palace building of his late Highness was one well-known feature of that sumptuous ruler's character. What to do with those gorgeous buildings was one of the difficulties of the English Government when it assumed the control of the country. One in which 200 of his wives and concubines had been magnificently housed is now turned into the zoological gardens. Where the fair Circassians lounged is the habitation of fierce beasts of prey. The marble walks laid out for the delicate feet of those ladies are now trodden by the gaping crowds of holiday Cairene visitors. Another palace has become a most sumptuous hotel. Another contains the priceless treasures of Egyptian antiquity at Gizeh. Several have been turned into soldiers' barracks, and many more are mouldering to decay. The insane of Egypt were not thought worthy of the best of those palaces. What was good enough for his Highness's horses was surely good enough for Egyptian lunatics. So to them was assigned the stable palace with its accessories. No doubt it was a great improvement on its predecessor, but under Egyptian management and control it was far from being an ideal hospital for the insane. Soon after Rogers Pasha was put at the head of the Sanitary Department, in which the treatment of the insane is merged, he saw that native management of the asylum was wanting in initiative, in honesty and in intelligence. So he got permission to appoint a British Medical Superintendent, and he has succeeded in investing him with large powers. Fortunately he secured the services of Dr. Warnock for the position. That gentleman's first Report, for 1895, now lies before us, and a most interesting document it is. We know from a visit we lately paid to the institution that the facts are true, and that the revolution from psychiatric darkness into light that has come about is very modestly understated. No man who has the welfare of the insane at heart but must rejoice that a great work is being thus carried out in behalf of the most helpless of mankind. Dr. Warnock's difficulties were at first enormous. He found dirt, disorder, and dishonesty rampant, neglect of the patients the rule, and modern scientific treatment of mental disease conspicuous by its absence. The patients were severely drugged, badly fed, insufficiently exercised, and vigorously restrained by means of the camisole. In and about one bed—a fair specimen of the rest—he counted 3,000 bugs, lice, and fleas, and now he fines the attendant in charge a piastre for every bug that is seen! In the year 1894 the death-rate was 33 per cent.; in 1895 it fell to 16½ per cent. on the average numbers resident, and in the last half of 1895 it fell one-third as compared with the first six months of that year. It must be kept in mind that the death-rate of the city of Cairo is about 40 per 1,000, or more than twice that of London. Organisation and order has been introduced everywhere. An almost entirely new and better staff has been engaged. When Dr. Warnock went there no female nurse could read the number on her ward door nor tell the time of day from the clock. Punctuality was unknown. There was no employment for either sex. Now we saw a very large number of men and women usefully at work. Noise by night and day has vastly diminished. Dr. Warnock says:—“Regularity and order are of slow growth, but in the end must prevail.” Parasites and the tubercle bacillus and the diseases they cause, have afforded the subordinate medical staff their chief employment, but Dr. Warnock looks hopefully forward to the time when a thorough mental and bodily examination of each case, systematised case-taking and the use of scientific methods, will bring his hospital up to the level of the British standard. The dietary has been improved in quality and service. There were 526 patients admitted in 1895, while the average number resident was only 465. We believe no such proportion of new cases to resident population exists in any asylum in Europe. This is not one of the least of the difficulties of proper treatment and management in the Cairo Asylum. Few of us would like to face such a yearly influx into our institutions. There is far too little land attached to this asylum, and it is too close to a public road. The structure and arrangements of the building fall far short of our European modern standard. Yet Dr. Warnock works on hopefully and successfully. He has to be doctor, steward, architect, clerk of works, and general manager. and all this with a staff of semi-civilised Arabs, scarcely one of whom he can trust as we trust our kitchen-maids! Let any man in Great Britain who is discontented with his asylum and his staff go to Cairo and spend a day with Dr. Warnock, and he will become profoundly thankful for his privileges. In his isolation from professional stimulus, with his stable-palace and its glaring structural defects, with his stolid Arab staff and his Arabian desert without a blade of grass as an outlook, he deserves our sympathy and admiration for what he has accomplished in his year of office, and for the pluck with which he faces his task. No one but an enthusiast could have done as much. All English officials in Egypt need to be young, healthy, hopeful, and tough. Their work takes a lot out of them.

While at Belriguardo Tasso wrote a letter to the Cardinal, who directed the Inquisition at Rome complaining that the Inquisitor at Bologna had made too little of his confessions, and that he had granted him absolution rather as to a lunatic than to a heretic. He actually proposed to come to Home to be accused in serious form. and not only did Torquato suspect his friends of denouncing him to the Inquisition, but he also accused them of heretical opinions, perhaps founded on some expressions they had used in familiar conversation. The Duke of Ferrara had, indeed, reason not only to be annoyed, but even to be seriously alarmed, for, though the Inquisitor at Bologna took a sensible view of Tasso's revelations, it was by no means certain that the Inquisition at Borne should look upon the matter in the same light. To a shrewd man who took Tasso's whole conduct into consideration he might seem deranged; but the poet possessed a wonderful power of vivid letter writing, and could make his fancies wear plausible shapes. Then the Duke's own mother was known to have been a favourer of the doctrines of Calvin, and some of the taint of heresy might be supposed to cling to Alfonso himself. He had enemies at Rome, and nothing is more credulous of evil reports than hatred. Perhaps they might favour the accusations in the hope of dispossessing him of his principality and causing it to revert to the Papal States, as was actually done after his death. About the same time Torquato wrote to his friend Gonzaga, “Either I am not only of a melancholy humour, but as it were mad, or I am too cruelly persecuted.” After ten days' stay at Belriguardo Alfonso sent Tasso back to Ferrara to be treated by his own physician. According to the pathology of the times melancholy was owing to humours rising to the brain. To expel these purgatives were the proper remedy. The poet was far from being submissive to treatment, and if the doctors did him no good they could always defend themselves by saying that their patient did not carry out their prescriptions. Tasso was kindly received at the convent of the Franciscans at Ferrara, which he repaid by accusations founded upon his ever-brooding suspicions. At another time he avowed his intention of becoming a brother of the Order.

American Journal of Insanity, April and July, 1895; Alienist and Neurologist, July, 1895; The Journal of Nervous and Mental Disease, June, 1895.

Dr. Clara Barrus writes in the American Journal of Insanity an article on “Gynæcological Disorders and their relation to Insanity.” She tabulates one hundred cases in which examinations were made whether the patient presented symptoms calling for uterine examination or not, and is of opinion that a thorough physical examination is necessary in all female cases, since the manifestations which would lead to examination were only noted in three patients. Very often the pain and discomfort felt by insane patients is misconstrued, and so, while we get no expression of pain itself, we may find the patient suffering from delusions that she is pregnant, that she has been violated during the night, and so on. A synopsis of the table is given, and shows the age of the patient, whether married or not, the presence or absence of menses, lencorrhóa or masturbation, of anomalies and new growths, the condition of the uterus and external genitalia, and the kind of mental disease which is presented. The gynæcologist who learns that it is the exception rather than the rule to find an insane woman with normal pelvic organs must be careful not to assign these abnormal conditions as a cause of insanity, but to keep an open mind, suspending his conclusions until further data can be examined. No doubt the causes of insanity in women are as varied and many of them are identical with the causes of insanity in men, but women have an additional physical and mental strain resulting from the crises which they have to undergo, such as the establishment of puberty, the monthly period, pregnancy, the puerperal state, and the climacteric. None of these by itself is sufficient to produce insanity, and when any of these experiences are said to be the cause of mental disease, we must acknowledge that though these may be the exciting cause, yet the predisposing one is an unstable organisation, causing the patient to be disturbed by occurrences which would only temporarily upset a healthy organism. As regards the table itself, one must guard against the erroneous opinion that the lesions which present themselves are associated more frequently with certain forms of insanity than with others, for although there were thirty-six cases of melancholia and twenty-one of dementia, and only nineteen of mania, ten of paranoia, and twenty-four of miscellaneous mental disorders, we must remember that cases of melancholia and dementia are more tractable and more easily examined, while those of acute mania, paranoia and sexual perversion are examined with difficulty. The author concludes that each case on admission should be examined, and if there is any abnormality present it should be removed if possible; by this means the degree of nerve irritation will be lessened and one of the “stumbling blocks” in the way of the patient's recovery will be removed.

Reference to Flechsig's Bromo-opiate Treatment of Epilepsy was made in the last number of this Journal. Though the results chronicled have so far been few in number, the adoption of this form of treatment in severe or obstinate cases of epilepsy, especially when associated with pronounced mental disturbance, appears worthy of consideration. In the Zeitschrift f. Psychiatrie, Bd. lii., two communications have appeared, each of which gives most favourable results. Linke has administered opium and bromides in succession to seven epileptics, six males and one female, in all of whom marked psychical aberration existed. In rapidly increasing doses he exhibited opium first for six weeks, suddenly changing the medicament to large doses (7·5 grms.) of bromide, which being continued for another period of six weeks was then reduced to a daily dose of 5 grms. This is the method advocated by Flechsig, though other therapeutists have lengthened the periods of administration of each drug. Linke found that during the opium course the epileptic seizures increased greatly in number, and that the body weight in some cases showed a marked diminution. As soon as the bromides were substituted for the opium the fits immediately diminished in frequency, and the body weight in the affected cases increased again. The ultimate result of the treatment was that in one patient the seizures had not recurred from the commencement of the bromide course until the date of his paper; in another, one fit occurred on the third day after beginning the bromides, and then after an interval of freedom for nine weeks two seizures ensued; a third patient had a fit on the first morning of the bromide treatment, after which an interval of sixty-five days without fits elapsed, when the bromide had to be discontinued owing to bromism; five days after its withdrawal the patient had another fit. With reference to the mental condition two patients showed a comparative improvement, they became more cheerful and patient of control; one of these, who had been subject to accessions of intense furor, subsequently remained quite free from them. Two of his seven patients died during treatment, one apparently by reason of deleterious action of opium on an affected cardiac muscle, the other owing to exhaustion due to the epileptic status. In nearly all a moderate degree of constipation was induced when the daily doses of opium reached ·60 grms., easily overcome, however, by simple aperients. When the maximum dose of opium was reached serious symptoms supervened, which rendered careful observation of each case needful. As only two and a half months had elapsed between the commencement of the bromide course and the publication of his paper, Linke discreetly draws attention only to the remarkable effects of this mode of treatment in cases hitherto wholly uninfluenced by therapeutic measures; he certainly makes no claim for the method as a specific curative.

The nineteenth Year-Book (1894) of the New York State Reformatory reflects, even at the first glance, the period of trouble from which the Reformatory has only lately emerged. It is a very plain and unpretentious document, without even a single illustration. Although the charges which have been brought against the Superintendent, Mr. Brockway, do not affect the special characteristics of the institution, i.e., the indeterminate sentence and the system of physical and psychic treatment now familiar to readers of this Journal, they tended to throw discredit upon the Reformatory, and moreover random and ignorant statements of the case appeared from time to time in England, even in influential medical journals. As the matter has cow been fully investigated and finally settled, it may be worth while briefly to set forth the results.

The Annual Meeting was held in the Rooms of the Association, 11, Chandos Street, London, W., on Thursday and Friday, July 23rd and 24th.