144 Psychological Retrospect
Nothing of importance has occurred during the past half-year regarding the progress of Psychological Medicine, either in its medical or legal relations. The long-talked-of Act of Parliament, dealing with the care and management of lunatics, has been again shelved to make way for matters of greater importance to the nation. The Bill has been altered so many times that it is impossible to give our readers any correct notion of what we are to expect as a result of the vast amount of evidence printed in the Report of the Select Committee of the House of Commons, appointed to inquire into the alleged grievances of lunatics. It may be mentioned that one of the chief instigators in getting up the inquiry, and one of the chief witnesses, has now departed this life for a better and a happier sphere; but it appears an extraordinary thiQg to us that any credence could have been given to his incoherent and irrational story of his quasi illegal confinement in several asylums. The Habitual Drunkards’ Act is an entire myth, and is a lamentable failure ; we want a compulsory Act, not a voluntary one, to check an increase in what is again at the head of the statistical causes of insanity. We have not heard so much of late of lunacy agitations or meetings, and,
perhaps, the propagators of these have now seen the error of their ways. No important lunacy trials have taken place since our last issue, and, in fact, there is nothing that can be called sensational in the lunacy world. With regard to the Census, and the preparation of the census papers in asylums, we may mention here that only the initials of the patients are sent to the office. This concession was made in consequence of an application that was made by the late Editor of this Journal, Dr Forbes Winslow, in 1851, to the Registrar-Greneral. This will doubtless relieve the minds of those who have relatives confined in Asylums and Institutions for the Insane. We give in extenso an interesting account taken from the Globe of March 2, describing ” A Turkish Madhouse ” :?
A Turkish Madhouse.?Constantinople, February 23.? Over the blue waters of the Bosphorus we start in a caique, shooting between countless steamers and sailing vessels; by heavy barges, full of gentle, scared-looking oxen and thousands of caged and cackling hens; past slim despatch boats, riding at anchor; and under the towering stern of grim ironclads, up whose wall-like black sides leaps the green, transparent wave. From the deck of one float the sounds of a military band braying forth a wild Turkish march?on over the buoyant sea which reflects the clouds, and the seagulls as they swing about on the fresh breeze. For a change has come, and the snow of last week has departed, and with it the dull, grey shroud of murky vapour which weighed on all. As we row on and on, away from Europe, and heading towards Asia, the music on the manof-war grows fainter and fainter; the clang and bellow of the Oriental melody, which, with all its barbarous cruelty and grandeur, ever preserves its pulsating rhythm, becomes soft and peaceful in the distance, and now reminds one only of the fitful cacenoes of a ” fantasia.” The bo’s’n’s whistle from a gunboat comes over the sea, and this, with the screech of the gulls and the ” whirr ” of a mallard, as he flies along with his neck out and his feet just skimming the water, is all we can hear. For the Kaikjy has ceased rowing, being engaged in rolling a cigarette, and the troupe of teal, which flit by at lightning speed, move as silently as the clouds overhead. These strange birds, for ever hurrying weirdly and noiselessly along the Bosphorus, are believed by the Turks to embody the souls of those who have perished in its limpid depths. There is no rest for them? they cease not to fly up and down, up and down the broad waterway between the two Continents?they are like the restless souls of purgatory, to whom peace is denied. The boatman blows a contented puff of smoke from the depths of his chest, stuffs his tobacco back into his girdle, spits in the water reflectively, and, as a sort of afterthought, resumes his oars. The jellyfish float by in thousands?they also look contented?and between us and the distant islands in Marmora Sea sport the black porpoises, evidently in the same enviable frame of mind. We are all content. There is Leander’s Tower on its islet, and more to the right rises the obelisk in the English cemetery, where sleep gallant officers, soldiers, and nurses, who died for their country’s glory in the bloody days of Inkermann and Sebastopol. We are now close to shore; in a few minutes Scutari is reached. Why attempt to vie with the many great word-painters who have borrowed every powerful adjective, and employed every graphic simile, to portray the view from the railings of the English cemetery, with its touching associations and sad stillness ? or the peaceful quiet of the great Mussulman burying-ground, its dark cypress groves, its dark subdued light, its countless white-turbaned tombstones ? Let me describe what I came to see?the native madliouse. Twenty minutes’ ride through the horribly-paved streets of Scutari, lined with wooden houses and shops?as inflammable as picturesque?up a steep hill, past the military training school, and we drew rein in front of an iron gate in a high wall. My companion was a charming Englishspeaking Turk?a nine-medal man, who had served her Majesty Queen Victoria in the Crimea, China, and the Indian Mutiny. Of him, more anon ; suffice it for the present, that, although a man of considerable standing, he very much doubted of his ability to get me?a stranger and a Christian?into the madhouse. ” If I set about it in the usual way,” he had said a few days before, ” there will be endless 4 permits’ and ‘ passes’ required, and the affair will take a week. Let us just ride straight up to the gates and see what ‘ backsheesh ‘ and an oily tongue will do.” On the way he purchased 50 packets of tobacco and some cigarette paper. It was a sight to see the ” thawing ” process through which the gate porter passed under the warm eloquence of my companion; frigid refusal became by turn violent protest and querulous argument, which soon gave place to remonstrance, melting into deprecating shouldershrugging, and at last unwilling consent. ” I shall be beaten and discharged, after ten years’ service, if I am caught,” grumbled the custodian. ” You shall neither be beaten nor discharged,” answered my friend. At last the gate was unchained and we entered. We stood under a large dome, which had evidently been a mosque, but now served as central hall, from which opened out passages leading to colonnaded courts. Sword and canes were taken from us, and then the porter looked at me and said something in Turkish to my friend. ” He says you can never go in amongst the lunatics with a hat; one or more are sure to fly at you.” So the porter lent me his fez, and with a couple of guards we turned down a passage and ascended some steps. First we visited a vast dormitory, extending round three sides of a court, and which was scrupulously clean, though dreadfully bare ; dull grey walls, and no pictures at all, not even gaudily-painted verses from the Koran, like one sees in Turkish barracks and hospitals. There was not a soul in this ward, for all the sufferers were in the court below. Looking down from the portico into this quadrangle, a strange sight met our view. Prowling about the open space, standing inanely passive and motionless, huddled up in the corners, or crouching at the foot of the wall, were some 200 men of all ages and colours?from vigorous youths, blasted by hereditary insanity, with flashing eye or vacant stare, to decrepid old age, lachrymose and mouthing?from the deadly-white face and grey beard of a Circassian, who had gone crazy of a fright, to the horrible grinning, coal-black Nubian, whose teeth shone like those of a jackal, whose great tongue was now and again protruded with fearful grimaces, and whose eyes flamed with the fierce fire of dangerous madness. There was one little fellow?a Turk?who kept on rolling along the earth at a great pace, laughing the while, and snapping, dog-like, at the heels of those who came in his way. There was another who remained huddled up in a heap, his head low down between his knees, and a sack over his shoulders. You might have looked long and not known tile brown bundle to be a man, only now and again this ghastly heap would spring up with a demoniacal shout, and stretch his meagre arms above his head, wailing sadly the while. Then he would collapse once more and remain motionless till another paroxysm. They wore grey and brown stuff, which looked like sacking?very coarse, but strong, warm, and clean; in fact, the whole place was cleanliness and order itself. On their heads were grey felt skull caps, and several were handcuffed, or rather a sort of leather tube kept their hands together in front of them, as though they were using a muff. Upon inquiry I heard that not a single patient was isolated in the establishment; only when they rave they get the ” muff.” When my companion said he wished to go down amongst the madmen and distribute the tobacco, our guards made some objection, but we went; eight strong warders accompanied us, and at the entrance my companion announced in a loud voice that I was a great doctor come to see them, and that if anyone behaved at all disagreeably, I should inevitably order him to be ” physicked “?a collective term, it would appear, in madhouse parlance, including terrible cold douches, leeches, terrific aperients, exhausting sweatings, and other drastic means of quieting the troubled mind. Like magic the mighty word acted on the jabbering horde, and I was astonished to see how much ratiocination remained in this sad collection of wrecked brains. Of course, all heeded it not; the drivelling idiot drivelled on, laughing and dancing around ; and some, whose stony, fixed stare and set lips denoted profound melancholy or idee fixe, stirred not, and paid no attention. But the great majority of those who crouched around us?and not a few looked threatening and wild?at once altered their demeanour?some even prostrated themselves, and begged and sobbed not to be “physicked.” But one big, copper-coloured fellow behaved very differently. He had been standing behind, and at my friend’s announcement plunged through the crowd, towering head and shoulders above them. ” Oh, madman,” he shouted in Arabic ; ” oh, dog, oh, filth of the high road! you would usurp my place; you would play the doctor amongst these poor wretches, when I?I, Allah’s own physician?omnipotent to kill or cure, am here !” The guards sprang forward just in time, for the giant would have proved a very tough customer; his eyes glared and the foam was at his lips. And now began the distribution of tobacco; and the guards had enough to do to prevent our being mobbed; eager claw-like hands sometimes snatched at. the bundle, and were only kept in check by looking the offender calmly in the face and saying “physic.” One poor devil sprang on my back and nearly strangled me, but was unceremoniously knocked off by a blow on the head from a warder. Very soon the 50 packets, each broken in two, were all gone.
“You might have brought some sweets,” said one man rather ungratefully to my friend; ” you see, being a camel, I cannot smoke, but I love sugar.” And so, promising to speak to the Sultan about one, to bring ” rah at lakum” to another, to come sailing into the court and carry off a third in a monster ship, and to accept ten million piastres and a thousand slaves from yet a fourth, we made good our retreat. After this we visited wards where lay the sick; we witnessed the ” physicking ” of one poor fellow?he was having leeches applied to his head, whilst hot fomentations were placed on the stomach. At the sight of us he sprang up with an irresistible bound, upsetting leeches, attendants, and everything. He stopped close to us and began to tremble, and chattered something in an awful hooting voice I shall never forget. I was told he always said the same thing, which was, ” The beard of the Prophet is long, but its hairs, placed on end, would not enclose the sea of blood in my head.” He stood there naked, his face flushed dark red, his teeth chattering, the black leeches hanging to his brow?a ghastly sight. Next instant the attendants had recaptured him. Need I say that we were glad to take our leave, and depart out of a place so rife with saddest sights and sounds. I may mention that we also saw a room full of boys?lads ranging from eight to fifteen?whose pitiful state was, perhaps, even more touching than that of the men. The women’s department we were not allowed to visit. Two things surprised me much?-the scrupulous cleanliness of everything, and the fact that no patients, even in the worst cases, are isolated?they are merely muffled as described above. There are always several guards in the courts and rooms, but accidents are not uncommon for all that; and I saw. two or three injured patients who were evidently the victims either of their own mania or that of their fellow-sufferers. ? The great barred gates swung to behind us, and we stood in the sunshine and the afternoon breeze from the sea. It was with a feeling of relief that we sprang into the saddle and cantered downhill to the landing-place.
Tests of Insanity.?Frederick John Woodfield, 32 years of age, described as a clerk, was charged at the Mansion House, on remand, with threatening to shoot his father, Mr. John Samuel Woodfield, a shipping agent, at 106 Fenchurch Street.?Mr. Herbert Alder Smith, medical officer at Christ’s Hospital, deposed that he had examined the prisoner, and was of opinion that his mind was very weak and unsound, and he had signed a certificate to that effect; but, having conferred with Mr. Gibson, he thought that, in a case of that kind, a second medical opinion should be had. He had examined the prisoner on various topics, and he had stated that his age was thirty-two and his father’s forty-five. He could not tell the Queen’s age or the number and names of her children; he was unaware who was Prime Minister, and he knew nothing of the Naval Demonstration against Turkey, though he had read the papers every day. These were a few of his statements.?The prisoner, interposing, said he had not seen the papers since he went to Newgate, and could not be expected to be up in the latest news. Moreover, he took no interest in politics, and made a point of never reading them. He protested against a medical man being sent by the Chief Clerk (whom he addressed as “Mr. Recorder”) to examine him.?Dr William Sedgwick Saunders, Medical Officer of Health for the City of London, said he had had twenty minutes’ conversation with the prisoner that morning on religious, social, and political subjects, and found that his thoughts were consistent and his memory intact. He could not testify that he was of unsound mind, but he thought he ought to be under observation in the workhouse infirmary for some little time.?The Chief Clerk said the Court had no power to send him there.?Dr Sedgwick Saunders said they did it at Guildhall Justice-room.?The Chief Clerk said, if they did, it was quite illegal.?Mr. Woodfield, the prisoner’s father, said the prisoner had no means of subsistence. He had been wandering in his mind and violent for some time, but the ast six months especially. Witness went in fear of him?in fact, he expected that the prisoner would be the death of him some day.?The prisoner complained that the Court had mixed up two cases most illegally. He was originally charged with threatening to shoot his father, which he denied, and now he was being made out to be of unsound mind, a calamity which he hoped would never befall him.?Sir Andrew Lusk said, looking at the very strong and pronounced opinions of Mr. Gibson and Mr. Alder Smith, and at the statement of Dr Sedgwick Saunders that he required to be under observation, he should send him to Stone, near Dartford.?The prisoner inquired what was Stone ??Sir Andrew Lusk said a charming and healthy place in Kent, where he would be well taken care of.?The prisoner said, at all events, he hoped he should have some good and wholesome food there. He then left the Court, and was subsequently conveyed to the City of London Lunatic Asylum at Stone.
A Meeting to consider the Prevention of Insanity.? The National Association for the Protection of the Insane held a meeting in Boston recently, which was notable in many ways. There was a lar^ge attendance, and the audience and speakers included the governor of the State and many prominent public and medical men.
The interest in the work of the Association was shown by the very full reports and comments published in the daily press. The Society has of late been receiving many new members, among whom are a dozen asylum superintendents, and two of these latter spoke at the meeting referred to. This and other facts tend to show that some impression is at last being made upon the closeness and conservatism of the Association of Insane Asylum Superintendents. The more liberal-minded in that body seem quite ready to appreciate the spirit and aims of the younger organisation. But, while making additions to its membership in all parts of the country, the remarks at the recent meeting indicated that considerable progress had been made in exciting public interest and securing practical reform. Governor Long, in a recent message to the Massachusetts Legislature, urged a number of new measures regarding the care of the insane upon that body. Some action in the matter, especially of classifying the insane, will undoubtedly be taken. A Bill has just been prepared providing for a staff of visiting physicians to the asylums. The work which has been done in Pennsylvania, and the difficulties that have attended it, were pointed out very forcibly by Dr Hiram Corson, trustee of the Pennsylvania State Insane Hospital, in a letter read at the Boston meeting.
He says, referring to the Association of Insane Asylum Superintendents : ” Your counsel would be of infinite service in aiding our efforts to counteract the selfish, pernicious influence of this Association. It may seem strange to you to hear me talk thus, but let me ask of you what reform in management of the insane has originated in that Society ? What but the invention and use of closer confinement, more means of restraint and seclusion of patients, and determined resistance to the reforms urged by philanthropists, who have witnessed how greatly they have ameliorated the miseries and contributed to the successful treatment of the insane ? I will not include all superintendents in this class of hostiles. There are many noble, humane, philanthropic men among them… . With much effort we have succeeded in preventing this Association from having any participation in the erection of the Eastern State Hospital at Norristown, and in reorganising the hospital at Harrisburg.”
One of the topics of discussion, opened by a letter from Dr. Joseph F. Parrish, was that of the etiology and prevention of insanity. Dr Parrish referred to the fact that insanity arose so largely among a wearied and restless class in whom bodily and mental vigour were sadly disproportionate. He believed that there ought to be more institutions for the treatment of persons who are only on the border-lines of insanity, in the ” crazy circle” of Crichton-Browne. Dr H. B. Wilbur, referring to the same subject, expressed his belief that insanity depended on predisposing causes?hereditary, social, and individual? rather than on exciting causes. While our civilisation increased it, education and study did not, if applied in the proper way. Dr Nathan Allen, speaking perhaps with the bias of a sanitarian, said that in his experience ill-health caused more insanity than any other agency. Dr Allen and Dr Kenniston, in a subsequent speech, asserted that intemperance was a great cause of insanity, and that any diminution in the former would equally affect the latter. Dr W. W. Godding feared that we must accept brain disease as one of the penalties of a higher development, hinting a possible future arrest of a growth of mind aspiring to be god-like.
There were many other letters and speeches upon the above and kindred subjects. The discussions contained much that was suggestive, and the result of the meeting will undoubtedly be the giving of a fresh impulse to a cause which deserves so entirely the encouragement and support it is receiving. The following excellent remarks are made by Dr Beard in his “Problems of Insanity”:?
General Defects of the Present Systems of Treating the Insane.?The main defects in the present treatment of the insane in Europe and America are these :
First: Neglect of the early stages. The best thing to do with disease is to prevent it; the next best is to cure it when it first appears; the last and least important of all is to attempt to cure its later stages; and it is with this last and least important duty that the asylums of the world are mainly occupied. When the time comes, as it will, when physicians shall be taught in the schools and the text-books, both how to diagnosticate and to treat the premonitory and warning signs of insanity, then the prognosis will be helped by a great percentage, and the statistics of asylums will give, and indeed they give now, but a most imperfect picture of what therapeutics of the modern school in expert hands can do for the treatment of the insane. The practical problem of the future is, how to educate physicians in the study of insanity so that they shall know its premonitory symptoms, and treat and cure it before it appears, or just after it appears. Already they are doing this for other diseases of the nervous system; they will in time do it for insanity. Already physicians in this country, and to a limited degree also in Europe, are beginning to study neurasthenia, which is the door that opens into so many phases of mental disease, and they are beginning to treat it and cure it, and to hold it in check so that it cannot and shall not go beyond itself. The insane must be treated before they are insane; we must arrest these cases on their way to the asylum ; we must seize them in the vestibule; we must snatch them away before the door closes upon them. There are a large number of cases of neurasthenia, of hysteria, and the allied disorders going on to insanity, and a large number of cases of insanity itself, as melancholia, and even mania, that can be treated, that ought to be treated, and that will be treated at home under the eye of nurses and friends in the direct and skilful charge of a family physician with the aid, if need be, of experts in the nervous system, on the same principles and by substantially the same methods as they now treat other diseases of the nervous system. Already this is being done ; already our best physicians in city and country are curing insanity without thought of an asylum, and they will do this far more in the twentieth century than noiv. The problems of insanity are to be solved outside of asylums more than in them. There is no prospect that the results of treatment with the very chronic insane will ever be very much more satisfactory than they are now. In almost all organic nervous diseases of long standing the cures are not very much more numerous than they were centuries ago. Every day of delay diminishes the chances. To treat the insane after they have become insane, is like taking in sail after the cyclone is fully upon us. Threefourths of the cases in asylums are cured in the first nine months.
Secondly. The second error in the treatment of the insane is in depending on simple isolation?shutting indoors and out of the sight of friends?negative without positive treatment. This isolation, this confinement, this restriction, this deprivaPSYCHOLOGICAL RETROSPECT. 153 tion of liberty is needful often, but not always, and it should never be used exclusively except in old and hopeless forms. In this respect, as in all respects, and as in all diseases, each case must be studied by and for itself in the light of general experience and on the principles of good sense. To decide this question of removal or of non-removal, it is needful to make a diagnosis not only of the patient but of the patient’s friends, and of his surroundings and of the psychology of the patient himself aside from his disease; we must know what he was in health, before he was taken down ; we must learn his intellectual and emotional qualities before we can tell whether the best place to treat him is without or within asylum walls. Just now there is a disposition, especially in France, but in this country also, to rely too much on seclusion or isolation alone in the treatment of neurasthenia and anemia and allied affections. Thirdly. The third evil in the present system of the treatment of the insane, both in Europe and America, is too much use of narcotics and sleep-forcing agents. This principle of treatment is as good for insanity as it is for any other nervous disease, but it is bad for all nervous diseases. These narcotics and stupefiers?our opium and our chloral?are simply rafts on which we step in an emergency; they are not the ships on which the patient is to voyage towards health; they who depend upon them will be likely to be cast upon the breakers and never reach the shore ; for such agents contain little power, or capacity for producing power; they are not tonics, but narcotics?useful, necessary, indispensable, of the highest value at certain crises. To systematically treat insanity in any of its phases, or neuralgia, or neurasthenia, or anaemia, or hysteria, or cerebral congestion, with individual exceptions, by narcotics, is not treating, but mistreating them, and the chief aim of the physician who understands these cases is to get them out of the need of these agents, to so renovate the nervous system that they shall not need them. That ideal, even though we fail to reach it, as we must in some cases, is the true and the only ideal in the scientific and successful treatment of diseases of the nervous system.
Fourthly. Treating curable and incurable cases together and excessive restraint; these evils are so obvious that they need no discussion. Europe and America are now protesting against them.
A very difficult practical problem of insanity is, hoiv to diagnosticate it. In diagnosing other diseases?fevers, inflammations and local troubles of every grade?we usually have time for quiet study, and repeated visits are oftentimes expected and needed, and there may be required also delay perhaps of days, before the physician arrives at a clehr and absolute conception of the nature of the disease from which the patient is suffering; but in insanity there is ofttimes an imperative want of a diagnosis at once on the spot, and this want must be met in some cases by a physician who is a stranger to the patient, and he is expected to decide the solemn question, whether the patient is or is not insane, by a single interview, and, on the facts gained from that interview alone, is to give his certificate for commitment. There is no other disease where the diagnosis is, as a rule, made so quickly, with so little study, or where the results are so important for the patient; and there is no disease where there is a greater need of study and time in order to gain absolute certainty in the diagnosis. In the severest forms, especially in the more violent forms of insanity, the diagnosis can be made by the friends, by the neighbours, by any passerby in the street; but in these subtler, elusive, tricky, intermittent and masked forms, that appear to be increasing in frequency in modern days, there is need of more facts and more study, and more deliberation and delay, than is possible in a single interview. In order to know whether a man is insane or not, we must know what that man is when he is sane; for conduct which is evidence of insanity in one man is simply sanity?<? perhaps eccentricity?in another.
The three great difficulties in the diagnosis are: (1) the determining where there is sufficient mental inco-ordination of a serious character; 2) the detection of insanity m some special directions on some particular themes, when there is perfect sanity in all others; and (3) the detection of the intermittent forms, where at times?perhaps the majority of the time?the patient is absolutely sane, having, perhaps, no recollection or suspicion of what he does or tries to do during his insane moments. There is no doubt that crimes of violence are done by persons who, at the time, are absolutely unconscious of what they are doing, and as irresponsible as a somnambulist. There is no doubt that excess in the use of certain stimulants and narcotics, as alcohol and opium, and very likely chloral, may induce a state of the brain where the condition of trance is liable to appear, which may last, perchance, for several hours or days; and while in this state the subject may commit crime, of which, on emerging from his normal state, he has no recollection. Some very remarkable cases of this have been lately published by my friend Dr T. D. Crothers, superintendent, of the Inebriate Asylum of Hartford, Connecticut. To this form of disease I have given the term “alcoholic trance,” inasmuch as it is simply a form of trance induced by alcohol. Dr Crothers has detailed eight cases of alcoholic trance, all of which are interesting.
In one case the patient, from his own statement, which the observation of others confirmed, would lose all consciousness, and wake, after a day or two, suddenly, the time having been to him entirely a blank; but during this interval he would carry on business as usual, his friends noticing nothing. At one time he acted as umpire at a sparring match, deciding correctly and giving satisfaction, yet had no recollection of what he did. He stated that all he remembered was, there was a proposition that he should be the umpire. This was followed by a glass of brandy, and then came a sudden forgetfulness of all events. One day he went to Eochester, drank hard, and lost all memory of what happened for three days, when he awoke in a hotel in New York. During this time he made sales and collections for his employer which were entirely correct, although lie ate and drank very little. This man suddenly died of some obscure affection of the brain.
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