Puerperal Insanity. The tendency of going on to recovery being almost certain.

Insanity of drinking of the acute form, where abstinence alone is necessary to prevent recurrence of the mental disease. Forms of insanity consequent on a debilitated state of health, such as from hyperlactation and starvation, where an improvement in the bodily and mental state has been gradual and coexistent.

Cases of excitement dependent on functional derangement, hysterical insanity.

Cases of recurrent attacks of mania, in which the history of the case distinctly shows a tendency to a short attack, and a long remission of the disease.

The home surroundings, the character of the patient's relatives, and in the working classes the facilities for the discharged patient at once getting steady work (this latter need not at present be considered, as anything in the shape of man gets work and is fairly paid) all combine either to militate against the patient's doing well out, or to aid in sending him back to the asylum.

I have known several patients, who appeared in every respect likely to remain well, have to be sent back to the asylum apparently from having to contend with home difficulties and circumstances which even a person who had not been insane must have found very trying indeed.

There can be little doubt but that the probability of a recently recovered case of insanity continuing well, is greatly increased by going to a well-ordered home, where the influences tend to increase self-control, and to put in use the laws of health. Many discharged patients, in whom hereditary predisposition is strongly marked, have, on recovery, to put up with considerable annoyance from their supposed sane relatives. There are at present several patients under my care, in whose case it has been a matter of wonder to me what mode of selection sent them to the asylum and left at large the relatives that visit them.

The class of cases which necessitate being kept for a considerable period under observation, are those in which melancholia has been a prominent feature, where impulsive actions have been very noticeable, and cases in which recurrence of maniacal attacks has been frequent and uncertain.

To arrive at a conclusion as to when it is safe to discharge patients whose mental state presented these phenomena, is undoubtedly a subject which demands the most careful con

sideration from the medical man, both as regards the safety of the patient and the public. In many cases the deceptive appearance of recovery would, I have no doubt, have caused a little anxiety in the mind of Solomon had he been in the practice of this branch of the profession.

In many of these cases of a doubtful nature, which one clearly recognises as requiring to be kept for a considerable time under observation, especially in those where a suspicion of a tendency to injure themselves has existed, one finds it most difficult to avoid discharging them at too early a date. The pressure of the patient's daily solicitation for discharge, his complaints of being quite well and kept in the asylum doing nothing for himself; the opinion of his relatives frequently backed up by that of, in their minds, a very wise neighbour, after an interview with the patient of about 20 minutes; all these, joined to the medical man's wish for as many recoveries as possible, and, perhaps, for room for an acute case, have their effect.

The tendency at present is, I think, undoubtedly rather to discharge patients who might be better kept in the asylum, than to detain persons who ought to be outside.

As

The question of testing the patient's mental state, by allowing him freedom in the asylum grounds or outside of them on parole, and discharge on probation, are subjects on which I should like to hear the experience of others. regards granting parole outside the grounds, the system does not act well at Garlands; the class of patients that have to be dealt with are too deficient in a sense of honour, and it appears to me that suitable steady work seems more beneficial than relaxations that are insufficiently appreciated. To those patients who have shown a tendency to self-injury, I think it is well to be guarded in granting parole, because, if an error in judgment occurred, and an unlooked-for self-injury took place, the result would be worse if it happened while the patient was an inmate of the asylum than if it occurred at his own home.

Discharge on probation seems to act very well in many ways. It facilitates the immediate return of the patient if unfit for life at home. It assists the patient to exercise all his self-control, to be aware that for a given time he is only on probation, and in certain cases it assists the relatives in dealing with self-willed convalescent patients.

The chief drawback about discharge on probation is that

it adds greatly to the anxiety of the asylum physician, who gets his fair share of that commodity.

To have to keep on the asylum books, and enter as would be done with a patient in the asylum, any accident that may befall a person who has been nearly a month a hundred miles from the asylum, is, I think, almost more than should be required.

A Visit to a Turkish Lunatic Asylum. - By JOHN H. DAVIDSON, M.D. Edin., Medical Superintendent of the Cheshire Asylum.

In the course of a tour, last autumn, through Greece, Turkey, and Asia Minor, I had the pleasure of making the acquaintance of the Physician-in-chief of the Asylum of Constantinople and neighbouring provinces, and through his courtesy and kind attention I was not only enabled to visit the Timar-khané, or Dari-chifa, as it is sometimes called, but also to obtain some interesting information respecting the care and treatment of the insane by the Turks more than three centuries ago. Up to a recent date, the insane were taken care of in the Asylum of Suleimanié, situated near the mosque of that name, but in consequence of the building being unable to meet the demands made upon it, the patients were removed to the Asiatic side of the Bosphorus, and lodged in the Asylum of Toptaschi in Scutari. The asylum, which is situated in the most Oriental and most beautiful suburb of Constantinople, on being approached, presents a rather dilapidated and neglected-looking appearance, and this aspect has been all the more heightened by the recent ravages of fire in the immediate vicinity; but the situation is most salubrious, as it catches the pleasant breezes from the Bosphorus and the sea of Marmora. The building is quadrangular, consisting of two storeys and surrounding a court, in the centre of which there is placed a fountain at which the patients perform their frequent daily ablutions before prostrating themselves in prayer at the calls of the muezzims from the minarets of the neighbouring mosques. The day and single rooms on the ground floor open into an arcade or colonnade which surrounds the entire building. The upper floor is used for dormitories which open into a corridor. In these the better class of patients sleep, and the more tur

bulent and excited sleep in the single rooms on the ground floor. The windows are protected by strong wire lattice instead of wooden lattice, as is the custom in all Turkish dwellings, and the flooring of both upper and under storeys is of tesselated pavement, which reminded me very much of that seen in the strada dell' abondanza in Pompeii.

The staff of the superior officers of the Asylum is composed of a Physician-Superintendent, two medical assistants, an under surgical assistant, a dispenser, an inspector, an imam, a secretary, and a steward. In addition to these, there are a cook, a laundress, and thirty-two attendants, eight of the latter being females, who are under the direction of the inspector, the only officer resident in the asylum. At the time of my visit, the asylum contained three hundred male and seventy-four female patients, the Caucasian, Ethiopian, and Mongolian races being each more or less fully represented. The paucity of females as compared with males is to be attributed, in a great degree, to deep-rooted religious scruples, for, so far as I could learn, mental alienation is not less prevalent in the East among the women than the men. It is certainly the dernier ressort with the Turks, the placing of females in an institution for the insane.

As regards the admission of patients to the Asylum it may be stated that there is no special law in the Ottoman empire upon the subject. A few simple formalities only are observed; and even in this enlightened age the Mussulmans only think of incarcerating such lunatics as are well known to be dangerous to themselves, or others, the popular notion being that the treatment of mental disorders is beyond the domain of medical science, and that the malady is only amenable to the skill of the exorcist. Patients must therefore have given undoubted proofs of furious mania before the Turks would dream of secluding them in an asylum. Except in the circumstances stated, all lunatics are allowed to remain at home, and some are even permitted to ramble about the streets in a state of complete nudity, their relations regarding them as objects of veneration and sources of prosperity.

As soon as a patient is brought to the Asylum, the doctor, or, in his absence, the secretary, furnished with a set form of questions, records the answers that he can gather from the relatives or friends who accompany the patient, and in those cases where the information appears insufficient, they are invited to return to the Asylum, that the answers to the inquiries may be completed. The fullest information is gene

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rally supplied by the police who bring cases to the asylum. The patient on admission is immediately washed and clothed in the asylum uniform, the patient's own garments being carefully stored away until the time comes when he may be in a condition to leave the asylum. In the event of death, however, all that belongs to him is handed over to his relations or heirs, but failing either, the Beit-ul-mal succeeds to his property. The process of washing being completed, the patient is conducted into the asylum court and placed among the other inmates. Immediate isolation is never resorted to except in cases where the patients are violent or suffering from bodily injuries. An obstreperous case is invariably restrained by means of the camisole and placed in a single room or cell until the arrival of the doctor, who usually orders a shower bath as a disciplinary measure. Those who have sustained bodily injuries are placed in small isolated chambers, and attendants, with trusty convalescent patients, are told off to watch and wait upon them.

All the inmates, poor or rich, Mussulmans or Christians, must be dressed in the Asylum clothing. The attendants themselves are attired exactly like the patients, except that there is a slight difference in the colour of the tunic and the head-dress. To each patient in the Asylum Government grants two suits annually, one for summer, and the other for winter wear. In summer the patients all wear a white-felt cap and a white linen vest, covered by a long variegated robe, like a dressing-gown, and tied in the middle with a worsted girdle; in winter a tunic of heavy cloth is substituted, over which is placed an outer garment, padded with wadding, and to the ordinary shoes worn are added the Turkish woollen slippers. This costume very much resembles that worn by Dervishes, and the felt head-dress contributes not a little to heighten this resemblance. In fact, from the dress of the patients, and the order and tranquillity which reign throughout the establishment at the Physician's visit, it has almost as much the appearance of a cloister of Dervishes as of a hospital for the insane. The body linen is changed weekly, and the external clothing once a month. This general change is preceded by a vapour bath, in which the patients are thoroughly cleansed and shaved. Personal cleanliness being strictly commanded by the laws of Islamism, the Mohammedan patients never, or very rarely, manifest the slightest reluctance to the bath, but rather the contrary. The PhysicianSuperintendent says that their love of the bath and of