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.

When one compares the few details left as about the life of Shakspere with the wealth of materials for writing the biography of Tasso we might suppose that there would be little doubt about the main facts in the life of the great Italian poet. Nevertheless some of the most important passages in his life have been the subject of controversy for the last 300 years. These questions especially regarded the treatment Tasso met with from the ducal family of Este, and unless we understand these relations correctly, we may totally misconceive the character of the poet and all the later events of his life. It seems strange that such questions have remained so long undecided; but biographers and critics are often much better acquainted with books and texts and languages than with human nature. A fine illustration of this is furnished by the Life of Tasso † by the Rev. Mr. Milman. Here we may refer the reader to a paper in this Journal of January, 1877. The author, whose initials are A. C. M., though his study of the life of Tasso had apparently gone no further than a perusal of Milman's book, was able to show many of the errors into which the biographer had fallen. In truth Mr. Milman, although he took up the traditional view that Tasso was the victim of vindictive persecution by the Machiavelian Duke of Ferrara, yet was too candid to repress a number of facts which, in the eyes of an able psychologist, showed that his whole treatment of the life of Tasso was founded upon a complete misconception or ignorance of the ordinary symptoms of mental derangement.

Our Association, which celebrated its jubilee at the Annual Meeting held at Birmingham in 1891, under the presidency of Mr. Whitcombe, numbers but few members who know much about its origin, formation, and early history, and it has occurred to me that it might be well if a record of it could be obtained and published while there yet remain among us some of the survivors of its earlier days. It will always be a regret to me that this was not taken in hand before the death of our greatly lamented colleague, Dr. Hack Tuke, who was one of our oldest and most devoted members, for he knew so much about its past history, and was personally acquainted with most, if not all, of the original members. Sir John C. Bucknill is, as far as I can ascertain, the sole surviving member of the Association in the days when the roll of members was a very small one, numbering between 30 and 40 at most, and his name first appears in our records in 1849.∗

Gentlemen,—I feel that some apology is due in bringing before you a series of rather trivial cases of mental disorder, in which there is nothing very new, and whose interest really lies in their being placed together for special consideration. Experience teaches me that one may often learn more from the slighter deviation from health than from the more serious perversions. In the former one may watch the details much more readily than one can in the latter.

More than a generation ago (in 1860), in Hamburg, I made my first experiment in treating patients suffering from recent insanity, especially the excited, in bed. This treatment, continued in the Göttingen Asylum, forms a prominent part of my system. It may therefore be inferred that the first experiments were confirmed by many excellent results; while, on the other hand, there have not been wanting occasional failures, which, indeed, attend on every method of medical treatment. I am glad to have an opportunity of laying my experience in this matter before the Medico-Psychological Association. My contribution may be taken as a small tribute in recognition of all I have learned from Great Britain throughout my psychiatric career, both in theory and practice.

Fifty years ago Baillarger† showed from a study of 453 cases that insanity is one third more frequently transmitted from the mothers to the children than from the fathers, and that in the case of sons the transmission is as frequently from one parent as from the other, and in the case of daughters the disposition to insanity is inherited twice as frequently from the mother as from the father. Leubuscher† apparently referring to some later statistics of Baillarger's dealing with 600 cases, found that:—

“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.

That it would be impossible for anyone in a single paper to adequately treat of the mental symptoms occurring in bodily diseases is self-evident. For it must be remembered, as Maudsley says, “that it is impossible to be out of sorts physically without being out of sorts mentally,” so that the subject includes not only the slight emotional changes found in various diseases, but also the actual insanities produced by or accompanying them. All that I propose to do in this communication is to give a short account of the mental changes which I have noticed during a four years' residence in the Manchester Royal Infirmary, and during a longer experience as visiting physician to the Manchester Workhouse Infirmary, where I have charge of over 800 medical beds.

I have nothing to say on changes of mental state due to loss of thyroid activity; the psychosis of cretinism [is well defined and widely known. But I venture to think that the mental changes of exophthalmic goitre are equally defined and not perhaps as widely realized. If this be so, if there are such distinct types of mental aberration, in marked antithesis to each other, which accompany two pathological states of the thyroid, perhaps also in antithesis, this is sufficient to give the subject a place in our discussion.

I propose to-day to discuss certain conditions of the circulatory system of the insane which are of interest clinically, and which have been illustrated by cases seen by me recently.

F. M., a domestic servant, aged 20 years, was received into the Inverness Asylum on 13th June, 1894, suffering from acute mania of about a fortnight's duration. There was no assigned cause for the attack, nor was a hereditary tendency to mental or nervous disease admitted.

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.

The case of W. C., a boarded-out lunatic, who recently made a murderous attack upon the wife and child of his guardian, has brought under public notice and discussion several matters connected with lunacy administration in Scotland. It would, obviously, be improper to discuss questions here which are still under the responsible consideration of the General Board of Lunacy. Therefore I do not intend to refer to such questions, and may venture to express the hope that the subsequent discussion will be confined to the one point raised, viz., the mode of procedure adopted by the criminal authorities.

The mental changes which accompany disturbances of the viscera may be classified under two groups, as follows:— (a) Those changes which accompany the disease directly, and are associated with the presence of some abnormal product or tissue change produced directly by the disease (for example, myxædema). These may be called the direct mental effects of visceral disease, and will be neglected in this communication. (b) Certain mental changes which are only present in those cases where the visceral disturbance causes what is known as referred pain associated with tenderness of the superficial structure of the body and scalp. Now this pain and tenderness are due to changes in some part of the central sympathetic system caused by disturbance of the internal organ to which sensory sympathetic nerves are supplied. Thus the mental changes of this group may be said to be indirect, for they are associated with visceral disturbances through the mediation of the sympathetic system. In this communication only the sensory and emotional changes are considered.

The subject-matter of this paper is one that I have always taken a great interest in since my connection with psychology, believing it to be the key-stone to modern treatment of the insane, and a valuable adjunct in setting a good example to a class of people who are prone to do evil as the result of their mental aberration, or the tendency to do nothing, or from want of something to do. It is a truism that work is a powerful antidote to low spirits, and if we contrast the asylum treatment of to-day with that of years ago, how strange and startling is the effect!

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.

I propose, in this paper, to give a brief account of an investigation carried out in Professor Kraepelin's laboratory at Heidelberg, and undertaken with the view of gaining some first-hand knowledge of the methods I brought before the notice of the Association last July.

At the outset it should be stated that, if the term diabetes is to necessarily include the three cardinal symptoms—permanent glycosuria, polyuria, and thirst—the term glycosuria should be added to the title of this paper. For several of the cases upon which it is based, and which, at the request of Dr. Claye Shaw, I am about to communicate to the Association, exhibit little beyond more or less permanent glycosuria. But, inasmuch as there is no abrupt line of demarcation between classical cases of diabetes and those where one or more of the symptoms are absent, and inasmuch as it has already been pointed out by other writers that the presence of mental symptoms is apt to mask the bodily ones, and, further, since allusion will be made to a few possible cases of diabetes insipidus, it has been deemed best to adhere to the original title which appeared in the list of subjects suggested for discussion at this meeting.

A short account of the proceedings in a case of lunacy in the State of Colorado may not be without interest and value to the readers of this Journal, as there has been some agitation in England for the establishment of a similar form of procedure. As each State makes its own laws in the matter, they vary in every State of the American Union. In Colorado the procedure for committing a lunatic consists, briefly, in trial by jury before a judge or what we should call in England a stipendiary magistrate, and precisely resembles the proceedings of a criminal trial in England.