The first edition of this text was published in 1905, and this third edition attests to its popularity, and to the author's desire for revision, much in evidence in this particular edition. Much attention is given to the latest findings on general paralysis of the insane, lately proven to be due to syphilis. There are sections on new trends in legislation and the new Mental Deficiency Act, and there is a short summary of psychoanalysis, cautiously reserving judgment on its efficacy. Most importantly, Craig has incorporated Kraepelin's findings on the classification of the functional psychoses into dementia praecox (schizophrenia) and manic-depressive insanity.
Stephen Trombley in 'All that Summer She was Mad', a book about Woolf and her doctors, spends much time selectively quoting from Craig and others, and denigrating their knowledge and abilities. He concentrates on their limited and often reactionary views on causation, but neglects to study their textbook descriptions of the types of illness from which Woolf suffered.
Bell says that she thought she was the cause of everyone's troubles, that it was her own fault, that there was nothing wrong with her, that people were laughing at her, and was overwhelmed with a sense of guilt, and felt that she should be punished. She believed that her body was 'monstrous', was disgusted by her mouth and belly, and refused to eat. Material things looked beastly and terrifying. She was anxious, slept poorly, and was so obviously suicidal that Leonard feared she would jump from the train on the journey back to London.
Craig says that melancholia often has a gradual onset with short periods of remission - evident in the 1913 months leading up to Woolf's overdose. The patient becomes 'more and more introspective', 'attention fails for external things and is centred on subjective thoughts and feelings of a dismal kind'. Sleep is disturbed.
'Self-accusation soon appears as a prominent symptom. Symptoms and circumstances are all viewed from the gloomy side'. The patient 'distorts early indiscretions into gigantic sins.......some patients say they are lost for ever .....they feel that they have sinned'. 'Extreme apprehension of some impending harm fills many with alarm, They misinterpret every sound and action into the movement and preparation of their persecutors'. '....if they consider it wrong to eat, or wicked to do any particular thing, they will deny themselves'.
Craig describes a type of 'hypochondriacal melancholy' with 'gastrointestinal hypochondriasis'. 'Many of these patients feel their abdomen is a huge sack and that food is accumulating there. they may tell you that their bowels have not opened for years. Refusal of food is often the most difficult symptom to treat, and may necessitate early removal to an asylum. Body weight usually falls rapidly'.
A similar comparison is made between Craig's description of mania and the symptoms described by Leonard in the excited phase of his wife's 1915 breakdown
It is difficult, even for a psychiatrist, to realise the severity and poor outcome of depression at that time. Nowadays patients seek help earlier and can be offered a range of fairly effective treatments, that, if not curative, prevent the development of more severe symptoms. Untreated, in 1913, refusal to eat could quickly lead to death, and often did so.
Craig gives figures for melancholia. 25% recover and keep well; 20% leave hospital and can do some work; 15% improve but are unfit for work and relapse; 35% remain permanently depressed, and 5% die in the acute phase of the illness. Craig believed that hallucinations of hearing, and refusal of food, both of which Woolf had, were of 'grave import'.
Faced with information of this kind was it any wonder that her doctors, Woolf's husband and the other members of the family feared then and in the next year or two, that she might never recover? And for the rest of her life that relapse and chronicity might occur?
On prognosis, Craig states that the immediate outlook is fairly good in those (like Woolf) who break down early in life; but the ultimate prognosis is poor, as these cases usually recur. He believes that 'with care, a great deal can be done to prevent relapse. Patients of this type should be taught how to live and the prophylactic measures they should follow'. It is unclear what this teaching involves. 'Give him careful instructions how he is to live in the future, so that he may avoid recurrences of depression; but impress upon him if he has any threatening of an attack to take advice early and be treated at once without waiting for the development of more serious symptoms. If the patient is suffering from the mixed form of maniacal-depressive insanity the relations must be warned to watch for the appearance of the symptoms of excitement'.
All this is the advice that Leonard Woolf must have been given by Craig in the years 1913 to 1915 and which he followed religiously for the rest of his wife's life.
His views on eugenics must have also have influenced his advice. Like many of his contemporaries he thought that psychiatric disorder was on the increase - he would be including severe learning difficulties in this rubric. Faced with their own therapeutic impotence, and convinced that hereditary factors played an important part in causing psychosis and mental handicap, they recommended that those who had suffered should not produce children. Undoubtedly these considerations were important in the advice that Leonard and Vanessa were given when they sought advice about the possibility of children. Not only would the doctors fear that childbearing would lead to relapse; they would fear that the risks of the child developing manic -depressive illness were increased. Time has provided some justification for their anxieties.
Craig had no effective curative treatment for this disorder other than treating the individual symptoms as best he could. He advised early treatment, believing that it shortened the course and reduced the risk of suicide. He considered that relatives and friends aggravated all the symptoms. He was much against travel, a common prescription for all nervous disorders at the time. 'Do not send him away on travel as is often done by the inexperienced; to do so is to court disaster'. He must have been unhappy at Woolf going off on holiday in 1913 when she was unwell, and concurred only to support a colleague and because she had been promised the trip.
'Rest is the treatment that is required'. The patient must be kept in bed for some time, and on no account must any mental work be permitted. Removal from home is nearly always needed. 'Most melancholics are very troublesome with their food, and if if this is not taken, forcible feeding must be resorted to'. He recommends various hypnotics to ensure rest and sleep.
Much that has been written about Woolf's husband and doctors has been very critical of them, suggesting that they formed a male conspiracy to dominate her, and that they made her ill. That they had failings by present day standards is not in doubt, but these were the failings of the historical period; to consult a doctor about a sick wife behind her back would not be regarded as unusual then, and might not today when the wife was psychotically depressed. But it should be remembered that the family at all times sought the very best advice available in the country, at fees they could ill afford, and that their conduct towards Woolf was entirely determined by the medical advice they were given. Among the doctors, Craig, who had most to do with her treatment over many years, was progressive and well informed for the time, and his diagnosis then would be agreed today. The main differences are in the availability of effective treatment, and in the reduced stigma and better outlook for manic depressive illness.
To deny that Woolf was ill, and her family uncaring, is an insult to her memory, and to the millions of manic-depressive patients and their relatives throughout the world who have struggled with these highs and lows for many years.
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