Art. III.?THE CURABILITY OF INSANITY. PSYCHOLOGICAL SHADOWS. BY W. A. F.
BROWNE, LL.D., formerly Medical Commissioner in Lunacy, Scotland. "
The earth hath bubbles, And these are of them."
as
the "water has,
When visiting a country hospital a few years ago, I encountered several individuals in the avenue who bore on their features traces and tinges of disease of some kind. It was the day of dismissal. Each of these discharged patients had in his hand a ticket inscribed with his name, the nature of his malady, the result, and so on. One of these persons, aged 45, but looking- older, allowed me to inspect his manumission, on which were written the words, " Bronchitis, recovered." The card of another was among others, " Intermittent fever, recovered." That of a third, who marked hobbled along on an artificial leg, or, rather, on what was then called a tree-leg, signified that he had laboured under strumous degeneration of the knee-joint. I put no questions to the exeunts, but was content with the sad, though perplexing " " history which the MS. of each disclosed. The word recovered was modest, and expressed in one sense the bare truth ; for I could not doubt for a moment that the seclusion of the sufferers in the hospital, the prudent diet and regimen and management there accessible, and the remedies and resources of art which had been resorted to, had, in different ways, promoted the recuperation of these patients, and enabled them to return to freedom, fresh air, their homes, and, under certain restrictions, their former occupations. But in what a vague, even contradic" " tory, acceptation must the word recovered be received ! Here from his allotted been subtracted is an elderly man, years having from all cardiac his saved from saved suffocating cough, span, and pulmonary changes which might have followed, by blisters, ipecacuanha, &c.; or, as the factors in such processes are multiple, by the mild and equable atmosphere by which he had been surrounded, and by protection from the low temperatures, the irregular habits, the want, perhaps the wickedness, which had provoked his affliction, and which will inevitably inflict a relapse should he expose himself to such causes or to his wallowing in the mire; and yet he was legitimately, according to prevailing opinions, discharged cured. Here is a second, who, having traversed the Fens of Lincolnshire, brought with him
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tlie poison, as well as the local experience, which his AngloSaxon forefathers must have borne innocuously. This lad had already been prostrated by several attacks of ague, but he had now been so lavishly saturated with quinine that his shivers and sweats had disappeared, that he felt active and athletic, that he dreaded no lagoon nor variation in the heat, moisture, or other qualities of the air?which, however, if braved recklessly in his native county, would inevitably send him to hospital with intermittent fever; and yet he was discharged cured. The cripple was in all probability admitted to the surgical ward when emaciated, feverish, and worn out by excruciating pain or discharges from his diseased member, and when the necessaries, had been exeven the loving kindness, of his humble home hausted. It is certain that judicious care and kindness had soothed his sufferings, and that amputation had saved his life. He seemed to cherish some notion of this kind as he hobbled exultingly and, so far as his walking-stick permitted, jauntily along. But this man must from henceforth be nearly or altogether incapable of resuming his toil as a labourer, must be cast upon parochial relief; and yet, indigent, maimed, mutilated, the remaining portion of the man was discharged cured. There is every reason to feel confident that the treatment of these unfortunate^ had been judicious and successful; that the infirmary, its staff and their manipulations, were outcomes of benevolence, and merited all the gratitude and all the praise which those who benefited by such ministrations, as well as the Christian hearts which supplied the resources, could expect or The episode is introduced not to condemn, but to desire. award unqualified approbation, except in one particular?the total absence of any scientific basis, rule, or even the faintest attempt to classify the recoveries which could fairly be boasted of. Here is a victim to bronchitis, with some alteration of tissue or function which imparts a tendency to new, repeated, and, finally, fatal attacks of the same disease ; here is a restored lad bearing in his system, in some inscrutable manner, a poison which needs but a breath of air to destroy health and to generate formidable or permanent maladies; and here is a sufferer whose life has been prolonged by deprivation of a limb, which renders him, if nothing more, a useless and helpless member of the community,?all being placed in the same category. In considering the difficulty, perhaps the impossibility, of reducing such elements to a classification which would render them available for statistical or medical purposes, it occurred to me that the results in the department with which I have been connected for a lifetime were recorded in a still more loose, imprecise, and even conjectural mode than that now sketched :
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indeed, the system pursued in asylums is still more emphatically to be repudiated; for while from hospitals the nature of the physical circumstances under which a patient is discharged is determined and declared by the medical attendant, who is alone entitled to pronounce such a verdict, this is not by any means the rule in all asylums. In one respect the decisions in both cases are open to the same objection?that there takes place an aggregation or slumping of diseases utterly discrepant in origin, form, and issue. Thus, while the cessation of ague and the loss of a limb are comprehended under the same designation, so are the terminations of mania, in all its varieties, of melancholia and dipsomania. It is quite obvious that, even when the mental condition, the fate, the future disposal of a lunatic are judged of by a medical expert, even by that expert who has guided and guarded his now sane charge through all the difficulties and dangers of a protracted paroxysm, there must be a thousand sources of fallacy, and that the conclusion as to the amount, or even the reality, of the convalescence may differ widely?nay, in many instances must differ widely?from that of other qualified experts. The first sources of fallacy may lurk in the medical judge's own mental and physical condition. He may be full of hope, he may be despondent, he may be ambitious
or
emulative of the
success
of others, he may be
suffering from physical, hepatic or renal disease, and his estimate of the qualities and bearing of those around, whether sane or insane, may and do not merely take a colouring, but are intrinsically influenced?it may be vitiated?by his bodily affliction or idiosyncrasy. The view taken of the progress and prospects of a patient will likewise depend in great measure upon the standard of health, trustworthiness, or usefulness assumed by whosoever may determine the complete or partial removal of alienation. According to the confessions of certain well-trained and acute physicians, great embarrassment may be encountered in forming a judgment from the peculiar habits of thought and the modes of expression of the individual undergoing examination. This obstacle is greatly magnified when the patient employs the local and unfamiliar language or the rude (almost
barbaric) dialects used in certain districts ; and becomes almost insurmountable when the inquiry is directed to members of the Celtic population?when the inquisitor and the inmate think and speak in different tongues, and can become intelligible to each other only through the medium of an interpreter, whose testimony is perhaps as confused and perplexing as that of the lunatic. I have known a well-disposed medical superintendent, who entertained a great horror for the violence, restlessness, destructive tendencies, and loquacity of those under his charge, accept the
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cessation of these manifestations of morbid activity as symptoms of incipient convalescence, if not of cure, and rest tranquilly upon the biblical picture, " Seated, clothed, and in his right mind." When to this self-satisfaction is added the vague and often rash expectancy that the amelioration initiated under treatment, or at all events during seclusion, may be promoted and secured under modified liberty, new and home influences, premature discharge may be explained if not justified. Upon such a theory, for it is little more, is founded the system of liberation In the opinion of many psychologists, such probaon probation. tion should be persevered in under the shelter and guidance and guardianship of a hospital; in fact, the entire duration of the residence of an individual in an institution for mental diseases is, subsequent to the more acute stages of disease, purely probationary, or tentative, or experimental. To those of timid, even to those of sensitive or sentimental character, the presence and co-mixture of persons only partially recovered from some form of mental derangement is alarming or repugnant, and excites somewhat of the same feeling which arises on the approach of a ticket-of-leave man. I have heard even those who were so far responsible for the legislative enactment under which this scheme was introduced confess grave doubts as to the expediency, even the legality, of such a procedure, and advocate the creation In Scotland, where of succursal or convalescent establishments. it would from the last report abound, appear probationers chiefly of the Commissioners in Lunacy that the experiment is not attended with triumphant results, as of 2,011 persons sent home on probation since 1862, 337 were again immured, within three months after liberation, in the asylum in- which they had been originally confined; while the remainder?those who did not return, of whom nothing was afterwards heard, but who may have died, been transplanted into another hospital, or may have deteriorated into fatuity, or some of the more tractable forms of derangement?are blazoned forth in the catalogue of recoveries. But my interest is chiefly awakened as to the fate of that large number who were not officially registered as relapsed, and cannot be fully allayed until it be demonstrated whether they were restored to reason, were incarcerated at a subsequent period, or died, or remained demented but inoffensive and tractable, and, In any of these as it often happens, useful members of society. supposed cases the objects aimed at in any speculation as to the curability of mental diseases are utterly stultified. It seems that this means of relieving plethoric asylums has not, even north of the Tweed, reached that degree of popularity which was imagined, as the Commissioners, in the report and at the page in which it is frequently requoted, mention only four asylums " it is seldom or never adopted." sorted to, while in the remainder
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Sucli vaticinations, for they are little else than hopeful conjectures, are sometimes founded upon accurate prognosis, often upon genuine benevolence, and may eventuate in that restoration which must be classed with the evidence of things not seen. But the step may be resolved upon under an erroneous interpretation of the mental condition of the subject. It may be dictated by a philosophical creed, by the notion that, if the intellect be clear and unclouded by delusions ; or, on the other hand, even should errors of judgment persist, if the emotions, the sentiments, the will, are apparently sound and self-regulating ; or, on another hand, even should there be observable less wisdom, less gentleness or self-control, should the passions or appetites have failed to dominate, or irresistibly to impel,?the portals of the prisonhouse are opened. Many judicious physicians, who have never analysed, even studied, the human mind in health, fail to grasp departures from its normal vigour and capacity, especially when the infirmity is, although significant, trivial and transitory, and confine their views to what is palpable and present, and, it may be, to indications afforded exclusively by the bodily condition. It is certain that, in many cases of general paralysis, recovery has been predicated and liberty granted in the lull which often succeeds the stage of excitement?when sufficient
reticence can be exercised to effect the concealment of any glaring and incredible Utopian visions, and when there is an obvious deposit of flesh and fat, and other deceptive symptoms of recuperation?the sufferer inevitably returning to pass through the subsequent stages of his fatal malady; but there is a more frequent and fertile source of error arising from that simulation of recovery presented during lucid intervals. This aspect of amendment is partly the result of genuine health, partly of that self-command possessed by many who are conscious of the conditions upon which their emancipation depends. There can be no doubt that the dismissal of individuals so affected is conceded in perfectly good faith, and may even become obligatory in consequence of their general deportment and the probability of future improvement. But when this issue is viewed broadly, and when thousands of individuals may be involved, the vitiation of all calculation as to the proportion of recoveries in the cloistered insane becomes painfully obvious. Every superintendent must see in his registers cases which have been removed once or twice, or oftener, during the year; and I can recall one upright and distinguished member of our specialty who was found deploring the death of M. M. on the plea that for years her cure had- been effected ten or a dozen times annually and thus enormously swelled the percentages. This course was pursued in all candour
THE
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honesty not merely as that generally, if not universally, prevalent, but because the cure was perfect, if not permanent, and because the law required it. But, when we examine the annals of another couutry, where different customs and opinions have regulated the practice of physicians, we find that one person is recorded as having recovered 59 times in twenty-two years, that another became sane 33 times, a third 22 times, a
and
fourth 10 times, 94 five times, and that 87 persons contributed 274 recoveries?an average of a fraction more than three to each person. We are somewhat staggered by the complexity and futility of any calculations based upon such premises. It should be noted that the difficulties thus created are so far explicable by the practice of treating such proportions as estimates on the number of cases and not of persons enumerated. But there are other and prolific means by which such scientific, though unintentional, exaggerations are committed. In one establishment it is stated that " the whole number of cases, of less than twelve months' duration, admitted since the opening of the institution was 1,061. Of these cases, 697, or sixty-five and sixty-nine hundredths per cent, recovered. Of these 1,061 cases, 187 were readmissions : hence, the number of persons admitted was 874. Eighty-seven of these persons recovered 274 times, or 187 times more than the These were duplicate or multiplicate number of persons. recoveries. Subtracting these (187) from the total (697) recoveries, the remainder is 510 recoveries, and these are the recoveries of persons." It is clear that when the absence of a lunatic from his school of training, the asylum, is brief?a mere vacation?as well as when his sanitary state is precarious and uncertain, such half recoveries, or quarter recoveries, should be relegated to that vague and meaningless limbo of removals under the term " improved " which figures so largely in certain statistical tables. But this subject presents other aspects. It has often happened that those who have laboured under delirium tremens and pseudo-dipsomania have, on the elimination of the alcoholic poisoning, been associated with those who have recovered from insanity. This is not so infinitesimal an element in such an investigation as might be imagined ; for in Scotland, where, in anticipation of the provisions of the Habitual Drunkards Act, individuals were entitled, under what is called a voluntary clause in an Act of Parliament, to consign themselves to an asylum, and again to discharge themselves whenso inclined, considerable numbers took advantage of this privilege. It may be charitably conceded that many such acts of self-denial were resorted to from a sincere anxiety to eradicate the morbid impulse and to avoid the temptations presented for its indulPART I.
VOL.
VI.
NEW SERIES.
Q
Q'l
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gence; but it is known that many of these inebriates adopted seclusion as the readiest refuge from bodily indisposition, or the social consequences of their errors, so that, when the malaise and the repentance had evaporated, they at once returned to the world and to their wallowing in the mire, but not until they had been honoured by a certificate of recovery. It has been averred that so numerous were the demands for admission under this clause, originally intended to facilitate the entrance of those trembling on the verge of madness and to avoid the painful ordeal of legal sanction, that medical superintendents, discovering the total inadequacy of such an arrangement to subdue an inveterate, if not an incurable, propensity, and recognising that the presence of even the most amiable of drunkards was a corrupting and contaminating element in the management of otherpatients, have, for some time, discouraged or discontinued the reception of such cases. It would be profitless to discuss, at this point, whether such affections can be legitimately classed with the neuroses or to question the validity of the opinion entertained b}r certain physicians as to the propriety of regarding relief from the miseries after a debauch with the rebound and exhilaration which sometimes mark the disappearance of gloom and melancholia ; but it is germane to our purpose that there may be latent considerations, undetected even by those who act under their influence, which countenance the undue multiplication and unintentional exaggeration of the beneficial effects of treatment. A temptation may arise to resort to early liberation in order to relieve the pressure from within or from without, where an asylum is crowded to excess and, as often occurs, by inoffensive dements, or where large numbers of recent clamant and dangerous cases require immediate admission ; and, should the superintendent be of a timid, irresolute, and sanguine disposition, he may yield to what cannot be otherwise stigmatised than as a compromise between two conflicting motives or duties. There may arise likewise a compulsion, exercised conscientiously, but tyrannically, by consultants, officials, or nondescript interlopers, to whose assumed penetration and advice the judgment is yielded, although an expert may be able to trace the germs of disease and even to predict a speedy relapse in the individual thus discharged cured. There is likewise a snare created by the pretended self-command of the patient under observation, by the assumption of external rationality, which in reality he possesses not, and by the concealment of prominent hallucinations and obnoxious qualities, in such a measure as to deceive alike medical and legal discrimination, and to lull to rest the suspicions of all around. But a more formidable source of error is incessantly presented
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by the conviction on the part of relatives and other responsible parties that their friend has been restored to health ; by their incessant importunities (even threats,) and by their assurances that their care and custody will accelerate amelioration?as it has done upon previous occasions?and another imperfectly restored But lunatic is in this way added to the general community. amongst these latent motives for the rapid and hazardous liberation of lunatics under treatment is the natural and most legitimate ambition of Superintendents to demonstrate to their fellow-
labourers and in the annals of science the success of some particular mode of treatment?medical, moral, or material; to secure a reputation?personal and for a particular hospital; or to support and corroborate theories as to the curability of insanity. It is fortunate that such feelings of emulation stimulate the efforts of the high-minded and self-sacrificing class entrusted with the charge of the insane, but the effect may be easily shown to be disastrous in over-estimating the remedial efficacy of medicine, and the influence of drugs, detention, and hygiene. History affords testimony that between 1684 and 1703 there were 1,294 patients admitted into Bethlehem, of whom 890 recovered, being a proportion of almost 69 per cent.; and further, that from 1784 to 1794, the proportion was 84 per cent.* It is to be specially noted that neither paralytics nor epileptics were received into this establishment during these periods, and that, making all due allowance for any conjectural change in the type or inveteracy of alienation in different stages of our civilisation, the recoveries were what at present are achieved and what may possibly be a normal ratio. But in 1820 there is a sudden augmentation in the number of recoveries, for a physician of high repute affirms that the cures of persons in his asylum reached the unprecedented amount of 91 percent, of recent cases, 35 of chronic cases, and 81 of all classes, even including the idiotic, the epileptic, and the fatuous. About the same time a popular writer of travels returned from a distant land with the somewhat startling intelligence that he had obtained irrefragable proof that 91 and three-tenths per cent, of cures had been effected under an experienced physician. Housed from passiveness or apathy to vaulting ambition, every Englishspeaking psychologist exerted his skill and?we must use the phrase?his ingenuity, in producing tables displaying what were conceived to be the triumphs of his art. Insanity became, in the eyes of the philanthropist, the most curable of formidable diseases, and, if taken during its earlier state and subjected to suitable remedies, must be cured, either by the efforts of *
Burrow's Commentaries. g
2
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or, as therapeutic agents were not then more potent infallible than now, must cure itself. It became a race, a struggle, a strife for distinction, and statistics exhibited a sudden rush upwards from the modest success of Tyson to the astounding maximum of 100, even 110, per cent. In the present day, when these gigantic proportions have shrunk to a more moderate size, it is almost inexplicable, in passing the eye over the long lines of figures and percentages, to conjecture how such conclusions could be arrived at. A superintendent, whose subsequent eminence is said to have entitled him to the title of Pinel Secundus, announced that he had restored to reason lunatics at the rate of 100 per cent. It should be carefully noted that this success applied to 13 patients only, one of whom died. Another expert reached the number quoted by Burrows, and even the calm and cautious Tuke, of the Retreat, averred that, according to his observation, there were curable, of recent cases 91 per cent., of old cases 35 per cent., of all cases 81 per cent. From other records we find that while, one superintendent can still boast of 100 per cent., a second falls to 99, a third oscillates between 82 and 94, a fourth has a variable rate from 82 to 93, a fifth reached 91, a sixth gives 80 to 90, while a seventh, a most honest and eminent historian of his own practice, inserts in his earlier chapters 80 per cent., but as the narrative proceeds, his success, or rather the mode upon which that success was computed, undergoes a signal alteration. It is incumbent here to protest that there is not the faintest insinuation as to the motives or the faithfulness under which such results are supposed to be arrived at. The explanation of the discrepancy which exists between past and present experience upon this point is to be sought for in the vicious or erroneous principles upon which these supposed facts are founded. In the first place, recoveries were estimated in reference to acute or recent cases only, such words signifying very different things and periods according to the convictions Instead of limiting recovery of acute cases of the recorder. to three months previous to admission, it might represent one year, and was, under all circumstances, indefinite and arbitrary. In the second place, the number of recoveries In the third was calculated on the number of discharges. and all chronic all incurable, epileptic, paralytic, place, idiotic cases, and even all deaths, were deducted from the gross numbers which were or had been under treatment, before the recoveries were dealt with; and these might then be compared with the admissions, the discharges, or even with the residuum still remaining in the asylum. It would be an insult to our existing convictions and to the principles, which may be
medicine, or
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the estimates of the results diseases to point out how utterly fallacious, deceptive, and Utopian were such practices ; but it is essential to our object to stigmatise them as subversive, on the one hand, of all correct notions as to prognosis in mental disease, and, upon the other, of the remedial powers which can be exercised for its removal or amelioration. In instituting any comparison between the results in different establishments, and in endeavouring to reconcile the palpable disparity between these which is conspicuous, various factors of restoration, as well as impediments to such an issue, must be embraced, as they intimately affect the general inquiry as to the duration and removal of alienation. Allusion has already been made to the influence of peculiarly constituted minds upon conclusions as to the present or potential benefit to the insane derived from medical interference ; but the actual benefits differ independently altogether from the opinions of the expert in different countries and classes, in relation to the profession or trade of the patient, to the average amount of intelligence and education prevailing in the district, to the immorality or intemperance or irreligion of which each individual may have been a victim, and to his original capacity and subsequent development. It is well known that where imbeciles? and there are communities of imbeciles?are attacked by delirium or excitement, that, in the rare instances of transitory mania? and we use the word advisedly and without any intention of entering on a qucestio vexata?and where mutual disturbance originates in poisons, not alcoholic, but generated in the system, such as in the urine, bile, &c., the continuance of the nervous ailment is brief, its removal of easy accomplishment, and the apparent rate of recovery is thus augmented. Where mental or moral epidemics occur this remark is especially applicable, and there is good reason for believing that not only do the seasons materially influence the cessation or promote the chronicity of the neurosis, but that these affections are more amenable to the resources of art at one time?for example, The experience of Tyson in one century?than in another. has already been quoted, showing that between 1684 and 1703 of 1,294 patients admitted into Bethlehem, 890 recovered, while in the same institution, where still only recent, curable, or non-paralytic cases are received, between 1846 and 1855 of 2,729 patients admitted, 1,479 recovered (Hood). Making all due allowance for a change in the type of disease, the discrepant opinions of medical superintendents, and the revolution insensibly taking place in the views of the medical profession generally, a more striking illustration is afforded by the following
now
pronounced catholic, regulating
of treatment in
nervous
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embraced was from September 30, 1868, In 1871 Dr. X resigned. Dr. W succeeded him in the superintendentship of the game asylum. The last three entire official years of the administration of Dr. X embraced the period from September 30, 1868, to October 1, 1871, and the first three of Dr. W, the period from September 30, 1872, to October 1, 1875. The statistics of these periods show that, during the first period, of 1,191 admissions 516 recovered, 43*32 per cent., and that, during the second, of 1,169 or admitted 269 recovered, or 22*16 per cent. Thus, although the number of admissions in the second period was but twentytwo less than in the first, the number of recoveries was but one We are not permitted even to suspect more than half as great. that any other feeling than legitimate professional rivalry could have actuated these labourers in the same field. Nor is even this conjecture admissible, as a marked declension in the fruits of the cultivation during the last harvest described is discernible. This comparative view is taken from the records of a public asylum, and in such alone is competition intelligible. Upon this ground it is desirable that the effects of treatment in private asylums under the management of trained and trustworthy medical experts?and there are many such?could be ascertained, as the very ungenerous argument that this class have a vested pecuniary interest in the detention of the persons consigned to their care must operate in preventing premature discharges, and many of the evils which may flow from a strain after public notoriety and the creation of an artificial reputation for the skill and success of the medical authorities. As next in reliability, may be ranged the recoveries in our public asylums, where the determination of the fact is arrived at by an educated responsible officer, who, although perhaps less or more influenced contrast.
The
to October
period
1, 1875.
by disturbing, though unconscious, sources of fallacy and error, acts according to the dictates of a deliberate judgment, and under the criticism of a vast jury composed of associates and fellow labourers. Such deliverances almost invariably vindicate the foregoing remarks as to the absence of uniformity in the effects of treatment; whether the disparity displayed be in the product of a difference in the standard employed, or in the perspicacity or imagination of the observer employing it, is not now discussed. For example, taking the annual reports of five large British public asylums for 1879, it appears that the percentage of cures ranges through 25, 33,40,41, 47 per cent. But it is highly probable that, at the present time, as when ThurIn round numbers, of ten persons attacked by nam wrote, insanity five recover and five die, sooner or later, during the "
attack.
Of the five who recover, not
more
than two remain
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during the rest of their lives. The other three sustain subsequent attacks, during which at least two of them die." Such estimates are unavoidably formed at the moment of the discharge of the patient and based upon the most trustworthy evidence accessible. These, although in one sense oracular, and the mere opinion of one person, must be accepted as data of great authority, seeing that the opinion thus emitted represents the prolonged observation and criticism of a scientific and conscientious expert, who, while he may be deceived by theories or hopes, cannot be suspected of deceiving others. But when it is known that in many institutions the emphatic declaration of discharged cured, and all its concomitant and consequent relations to psychological inquiry, is pronounced by a board of county gentlemen, who may, or may not, be guided by the convictions of their subordinates in the management of the house, it is natural to recoil from the perplexing confusion which may thus arise as to the absolute reality and degrees of the curability of the insane. It is well known that in many asylums, before the removal of an inmate to his house, there must be an appearance before the directors, so that the report of the superintendent, as well as the health, capacity, self-control of the postulant, may be tested, and, as is generally the case, This practice may prove a confirmed by the bureaucracy. guide and a guarantee to the public, but is neither complimentary to medical discrimination or honesty, nor conducive to accuracy in speculation on the progress and termination of disease. The board supposed to be thus engaged generally consists of men of high birth, ample education, unimpeachable integrity, and unselfish feelings, so that their deliberations and verdict are entitled to perfect respect, although they cannot be hailed as truths of Holy Writ or as scientific conclusions. But when such a body is composed of parish guardians, or, what is equivalent in Scotland, the parochial board, and when the members, whose honesty of purpose we do not here call in question, may be the butcher, baker, undertaker, &c. of the village, borough, or union?who, unless inspired, cannot possess any of the qualities which enable the observer to judge of the mental condition, either in health or in disease, of any individual; and who, whatever may be their humanity and sympathy, and their independence of spirit, cannot fail to be influenced by the selfish, or they may be honourably designated, the social and patriotic interests of their constituents?it is difficult to avoid a smile, or a shudder, over the havoc which may accrue to medical statistics, and the injuries which may be reflected upon families
well
and communities as well as the individual under examination. But such fiat may depend upon the impressions of a single
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observer?the relieving officer in one country, the inspector of poor in another?who are constrained to act in accordance with their brief, or their own very partial information. When liberation is effected by a family council, or by the decision of friends, who have no opportunity of watching the peculiarities of their cloistered relatives, and who are animated by a natural and justifiable anxiety to promote the well-being of the person in whom they are interested, and to secure the supposed advantages of freedom, home, and original pursuits and pleasures, the risks of such interference are greatly multiplied, and to this source may be attributed the majority of the relapses which crowd the columns of the register of every public institution. But the inmates of such establishments, particularly where they belong to the affluent ranks, may be removed from treatment in a number of other ways. They may be dismissed by the authority of medical, legal, or official assessors, of high national or public functionaries, acting with or without advice, with or without any explanation of the grounds on which action has been taken, of the objects proposed, and, it has happened, in direct opposition to the experience and warnings of those who have cared for and scrutinised the symptoms, and have arrived at well-digested opinions ds to the probabilities of perfect and permanent restoration to health. But into the possible mistakes or misdoings of these possessors of power I hesitate at present to enter.
From this vidimus, which is, unfortunately, far from exI have endeavoured to exclude all considerations of self-interest and pecuniary gain, because I believe that such unworthy incentives are of rare occurrence, and cannot materially affect speculations as to the ultimate issues of mental diseases. In compliance with what is almost the universal custom of those who have been engaged in exposing abuses, errors, and the miscarriages of philosophy and philanthropy, I would very humbly venture to suggest, as a means of preventing or lessening the evil complained of, the creation of a corps of experts, as has been proposed for other purposes, and which might be incorporated with the Board of Commissioners, or who might be constituted from properly qualified medical men, upon whose judgment and decision alone, in conjunction with those of the ordinary hospital superintendent, should depend the liberation of every patient. It is incumbent to acknowledge my indebtedness to a " pamphlet on The Curability of Insanity," by Dr. Pliny Earle, Northampton, Massachusetts, for many facts in this article.
haustive,
BROWNE, LL.D., formerly Medical Commissioner in Lunacy, Scotland. "
The earth hath bubbles, And these are of them."
as
the "water has,
When visiting a country hospital a few years ago, I encountered several individuals in the avenue who bore on their features traces and tinges of disease of some kind. It was the day of dismissal. Each of these discharged patients had in his hand a ticket inscribed with his name, the nature of his malady, the result, and so on. One of these persons, aged 45, but looking- older, allowed me to inspect his manumission, on which were written the words, " Bronchitis, recovered." The card of another was among others, " Intermittent fever, recovered." That of a third, who marked hobbled along on an artificial leg, or, rather, on what was then called a tree-leg, signified that he had laboured under strumous degeneration of the knee-joint. I put no questions to the exeunts, but was content with the sad, though perplexing " " history which the MS. of each disclosed. The word recovered was modest, and expressed in one sense the bare truth ; for I could not doubt for a moment that the seclusion of the sufferers in the hospital, the prudent diet and regimen and management there accessible, and the remedies and resources of art which had been resorted to, had, in different ways, promoted the recuperation of these patients, and enabled them to return to freedom, fresh air, their homes, and, under certain restrictions, their former occupations. But in what a vague, even contradic" " tory, acceptation must the word recovered be received ! Here from his allotted been subtracted is an elderly man, years having from all cardiac his saved from saved suffocating cough, span, and pulmonary changes which might have followed, by blisters, ipecacuanha, &c.; or, as the factors in such processes are multiple, by the mild and equable atmosphere by which he had been surrounded, and by protection from the low temperatures, the irregular habits, the want, perhaps the wickedness, which had provoked his affliction, and which will inevitably inflict a relapse should he expose himself to such causes or to his wallowing in the mire; and yet he was legitimately, according to prevailing opinions, discharged cured. Here is a second, who, having traversed the Fens of Lincolnshire, brought with him
THE
CURABILITY
OF
INSANITY.
77
tlie poison, as well as the local experience, which his AngloSaxon forefathers must have borne innocuously. This lad had already been prostrated by several attacks of ague, but he had now been so lavishly saturated with quinine that his shivers and sweats had disappeared, that he felt active and athletic, that he dreaded no lagoon nor variation in the heat, moisture, or other qualities of the air?which, however, if braved recklessly in his native county, would inevitably send him to hospital with intermittent fever; and yet he was discharged cured. The cripple was in all probability admitted to the surgical ward when emaciated, feverish, and worn out by excruciating pain or discharges from his diseased member, and when the necessaries, had been exeven the loving kindness, of his humble home hausted. It is certain that judicious care and kindness had soothed his sufferings, and that amputation had saved his life. He seemed to cherish some notion of this kind as he hobbled exultingly and, so far as his walking-stick permitted, jauntily along. But this man must from henceforth be nearly or altogether incapable of resuming his toil as a labourer, must be cast upon parochial relief; and yet, indigent, maimed, mutilated, the remaining portion of the man was discharged cured. There is every reason to feel confident that the treatment of these unfortunate^ had been judicious and successful; that the infirmary, its staff and their manipulations, were outcomes of benevolence, and merited all the gratitude and all the praise which those who benefited by such ministrations, as well as the Christian hearts which supplied the resources, could expect or The episode is introduced not to condemn, but to desire. award unqualified approbation, except in one particular?the total absence of any scientific basis, rule, or even the faintest attempt to classify the recoveries which could fairly be boasted of. Here is a victim to bronchitis, with some alteration of tissue or function which imparts a tendency to new, repeated, and, finally, fatal attacks of the same disease ; here is a restored lad bearing in his system, in some inscrutable manner, a poison which needs but a breath of air to destroy health and to generate formidable or permanent maladies; and here is a sufferer whose life has been prolonged by deprivation of a limb, which renders him, if nothing more, a useless and helpless member of the community,?all being placed in the same category. In considering the difficulty, perhaps the impossibility, of reducing such elements to a classification which would render them available for statistical or medical purposes, it occurred to me that the results in the department with which I have been connected for a lifetime were recorded in a still more loose, imprecise, and even conjectural mode than that now sketched :
78
THE
CURABILITY OF INSANITY.
indeed, the system pursued in asylums is still more emphatically to be repudiated; for while from hospitals the nature of the physical circumstances under which a patient is discharged is determined and declared by the medical attendant, who is alone entitled to pronounce such a verdict, this is not by any means the rule in all asylums. In one respect the decisions in both cases are open to the same objection?that there takes place an aggregation or slumping of diseases utterly discrepant in origin, form, and issue. Thus, while the cessation of ague and the loss of a limb are comprehended under the same designation, so are the terminations of mania, in all its varieties, of melancholia and dipsomania. It is quite obvious that, even when the mental condition, the fate, the future disposal of a lunatic are judged of by a medical expert, even by that expert who has guided and guarded his now sane charge through all the difficulties and dangers of a protracted paroxysm, there must be a thousand sources of fallacy, and that the conclusion as to the amount, or even the reality, of the convalescence may differ widely?nay, in many instances must differ widely?from that of other qualified experts. The first sources of fallacy may lurk in the medical judge's own mental and physical condition. He may be full of hope, he may be despondent, he may be ambitious
or
emulative of the
success
of others, he may be
suffering from physical, hepatic or renal disease, and his estimate of the qualities and bearing of those around, whether sane or insane, may and do not merely take a colouring, but are intrinsically influenced?it may be vitiated?by his bodily affliction or idiosyncrasy. The view taken of the progress and prospects of a patient will likewise depend in great measure upon the standard of health, trustworthiness, or usefulness assumed by whosoever may determine the complete or partial removal of alienation. According to the confessions of certain well-trained and acute physicians, great embarrassment may be encountered in forming a judgment from the peculiar habits of thought and the modes of expression of the individual undergoing examination. This obstacle is greatly magnified when the patient employs the local and unfamiliar language or the rude (almost
barbaric) dialects used in certain districts ; and becomes almost insurmountable when the inquiry is directed to members of the Celtic population?when the inquisitor and the inmate think and speak in different tongues, and can become intelligible to each other only through the medium of an interpreter, whose testimony is perhaps as confused and perplexing as that of the lunatic. I have known a well-disposed medical superintendent, who entertained a great horror for the violence, restlessness, destructive tendencies, and loquacity of those under his charge, accept the
THE
CURABILITY OF INSANITY.
79
cessation of these manifestations of morbid activity as symptoms of incipient convalescence, if not of cure, and rest tranquilly upon the biblical picture, " Seated, clothed, and in his right mind." When to this self-satisfaction is added the vague and often rash expectancy that the amelioration initiated under treatment, or at all events during seclusion, may be promoted and secured under modified liberty, new and home influences, premature discharge may be explained if not justified. Upon such a theory, for it is little more, is founded the system of liberation In the opinion of many psychologists, such probaon probation. tion should be persevered in under the shelter and guidance and guardianship of a hospital; in fact, the entire duration of the residence of an individual in an institution for mental diseases is, subsequent to the more acute stages of disease, purely probationary, or tentative, or experimental. To those of timid, even to those of sensitive or sentimental character, the presence and co-mixture of persons only partially recovered from some form of mental derangement is alarming or repugnant, and excites somewhat of the same feeling which arises on the approach of a ticket-of-leave man. I have heard even those who were so far responsible for the legislative enactment under which this scheme was introduced confess grave doubts as to the expediency, even the legality, of such a procedure, and advocate the creation In Scotland, where of succursal or convalescent establishments. it would from the last report abound, appear probationers chiefly of the Commissioners in Lunacy that the experiment is not attended with triumphant results, as of 2,011 persons sent home on probation since 1862, 337 were again immured, within three months after liberation, in the asylum in- which they had been originally confined; while the remainder?those who did not return, of whom nothing was afterwards heard, but who may have died, been transplanted into another hospital, or may have deteriorated into fatuity, or some of the more tractable forms of derangement?are blazoned forth in the catalogue of recoveries. But my interest is chiefly awakened as to the fate of that large number who were not officially registered as relapsed, and cannot be fully allayed until it be demonstrated whether they were restored to reason, were incarcerated at a subsequent period, or died, or remained demented but inoffensive and tractable, and, In any of these as it often happens, useful members of society. supposed cases the objects aimed at in any speculation as to the curability of mental diseases are utterly stultified. It seems that this means of relieving plethoric asylums has not, even north of the Tweed, reached that degree of popularity which was imagined, as the Commissioners, in the report and at the page in which it is frequently requoted, mention only four asylums " it is seldom or never adopted." sorted to, while in the remainder
80
THE
CURABILITY OF
INSANITY.
Sucli vaticinations, for they are little else than hopeful conjectures, are sometimes founded upon accurate prognosis, often upon genuine benevolence, and may eventuate in that restoration which must be classed with the evidence of things not seen. But the step may be resolved upon under an erroneous interpretation of the mental condition of the subject. It may be dictated by a philosophical creed, by the notion that, if the intellect be clear and unclouded by delusions ; or, on the other hand, even should errors of judgment persist, if the emotions, the sentiments, the will, are apparently sound and self-regulating ; or, on another hand, even should there be observable less wisdom, less gentleness or self-control, should the passions or appetites have failed to dominate, or irresistibly to impel,?the portals of the prisonhouse are opened. Many judicious physicians, who have never analysed, even studied, the human mind in health, fail to grasp departures from its normal vigour and capacity, especially when the infirmity is, although significant, trivial and transitory, and confine their views to what is palpable and present, and, it may be, to indications afforded exclusively by the bodily condition. It is certain that, in many cases of general paralysis, recovery has been predicated and liberty granted in the lull which often succeeds the stage of excitement?when sufficient
reticence can be exercised to effect the concealment of any glaring and incredible Utopian visions, and when there is an obvious deposit of flesh and fat, and other deceptive symptoms of recuperation?the sufferer inevitably returning to pass through the subsequent stages of his fatal malady; but there is a more frequent and fertile source of error arising from that simulation of recovery presented during lucid intervals. This aspect of amendment is partly the result of genuine health, partly of that self-command possessed by many who are conscious of the conditions upon which their emancipation depends. There can be no doubt that the dismissal of individuals so affected is conceded in perfectly good faith, and may even become obligatory in consequence of their general deportment and the probability of future improvement. But when this issue is viewed broadly, and when thousands of individuals may be involved, the vitiation of all calculation as to the proportion of recoveries in the cloistered insane becomes painfully obvious. Every superintendent must see in his registers cases which have been removed once or twice, or oftener, during the year; and I can recall one upright and distinguished member of our specialty who was found deploring the death of M. M. on the plea that for years her cure had- been effected ten or a dozen times annually and thus enormously swelled the percentages. This course was pursued in all candour
THE
81
CURABILITY OF INSANITY.
honesty not merely as that generally, if not universally, prevalent, but because the cure was perfect, if not permanent, and because the law required it. But, when we examine the annals of another couutry, where different customs and opinions have regulated the practice of physicians, we find that one person is recorded as having recovered 59 times in twenty-two years, that another became sane 33 times, a third 22 times, a
and
fourth 10 times, 94 five times, and that 87 persons contributed 274 recoveries?an average of a fraction more than three to each person. We are somewhat staggered by the complexity and futility of any calculations based upon such premises. It should be noted that the difficulties thus created are so far explicable by the practice of treating such proportions as estimates on the number of cases and not of persons enumerated. But there are other and prolific means by which such scientific, though unintentional, exaggerations are committed. In one establishment it is stated that " the whole number of cases, of less than twelve months' duration, admitted since the opening of the institution was 1,061. Of these cases, 697, or sixty-five and sixty-nine hundredths per cent, recovered. Of these 1,061 cases, 187 were readmissions : hence, the number of persons admitted was 874. Eighty-seven of these persons recovered 274 times, or 187 times more than the These were duplicate or multiplicate number of persons. recoveries. Subtracting these (187) from the total (697) recoveries, the remainder is 510 recoveries, and these are the recoveries of persons." It is clear that when the absence of a lunatic from his school of training, the asylum, is brief?a mere vacation?as well as when his sanitary state is precarious and uncertain, such half recoveries, or quarter recoveries, should be relegated to that vague and meaningless limbo of removals under the term " improved " which figures so largely in certain statistical tables. But this subject presents other aspects. It has often happened that those who have laboured under delirium tremens and pseudo-dipsomania have, on the elimination of the alcoholic poisoning, been associated with those who have recovered from insanity. This is not so infinitesimal an element in such an investigation as might be imagined ; for in Scotland, where, in anticipation of the provisions of the Habitual Drunkards Act, individuals were entitled, under what is called a voluntary clause in an Act of Parliament, to consign themselves to an asylum, and again to discharge themselves whenso inclined, considerable numbers took advantage of this privilege. It may be charitably conceded that many such acts of self-denial were resorted to from a sincere anxiety to eradicate the morbid impulse and to avoid the temptations presented for its indulPART I.
VOL.
VI.
NEW SERIES.
Q
Q'l
THE
CURABILI1Y OF INSANITY.
gence; but it is known that many of these inebriates adopted seclusion as the readiest refuge from bodily indisposition, or the social consequences of their errors, so that, when the malaise and the repentance had evaporated, they at once returned to the world and to their wallowing in the mire, but not until they had been honoured by a certificate of recovery. It has been averred that so numerous were the demands for admission under this clause, originally intended to facilitate the entrance of those trembling on the verge of madness and to avoid the painful ordeal of legal sanction, that medical superintendents, discovering the total inadequacy of such an arrangement to subdue an inveterate, if not an incurable, propensity, and recognising that the presence of even the most amiable of drunkards was a corrupting and contaminating element in the management of otherpatients, have, for some time, discouraged or discontinued the reception of such cases. It would be profitless to discuss, at this point, whether such affections can be legitimately classed with the neuroses or to question the validity of the opinion entertained b}r certain physicians as to the propriety of regarding relief from the miseries after a debauch with the rebound and exhilaration which sometimes mark the disappearance of gloom and melancholia ; but it is germane to our purpose that there may be latent considerations, undetected even by those who act under their influence, which countenance the undue multiplication and unintentional exaggeration of the beneficial effects of treatment. A temptation may arise to resort to early liberation in order to relieve the pressure from within or from without, where an asylum is crowded to excess and, as often occurs, by inoffensive dements, or where large numbers of recent clamant and dangerous cases require immediate admission ; and, should the superintendent be of a timid, irresolute, and sanguine disposition, he may yield to what cannot be otherwise stigmatised than as a compromise between two conflicting motives or duties. There may arise likewise a compulsion, exercised conscientiously, but tyrannically, by consultants, officials, or nondescript interlopers, to whose assumed penetration and advice the judgment is yielded, although an expert may be able to trace the germs of disease and even to predict a speedy relapse in the individual thus discharged cured. There is likewise a snare created by the pretended self-command of the patient under observation, by the assumption of external rationality, which in reality he possesses not, and by the concealment of prominent hallucinations and obnoxious qualities, in such a measure as to deceive alike medical and legal discrimination, and to lull to rest the suspicions of all around. But a more formidable source of error is incessantly presented
THE
CURABILITY
OF
83
INSANITY.
by the conviction on the part of relatives and other responsible parties that their friend has been restored to health ; by their incessant importunities (even threats,) and by their assurances that their care and custody will accelerate amelioration?as it has done upon previous occasions?and another imperfectly restored But lunatic is in this way added to the general community. amongst these latent motives for the rapid and hazardous liberation of lunatics under treatment is the natural and most legitimate ambition of Superintendents to demonstrate to their fellow-
labourers and in the annals of science the success of some particular mode of treatment?medical, moral, or material; to secure a reputation?personal and for a particular hospital; or to support and corroborate theories as to the curability of insanity. It is fortunate that such feelings of emulation stimulate the efforts of the high-minded and self-sacrificing class entrusted with the charge of the insane, but the effect may be easily shown to be disastrous in over-estimating the remedial efficacy of medicine, and the influence of drugs, detention, and hygiene. History affords testimony that between 1684 and 1703 there were 1,294 patients admitted into Bethlehem, of whom 890 recovered, being a proportion of almost 69 per cent.; and further, that from 1784 to 1794, the proportion was 84 per cent.* It is to be specially noted that neither paralytics nor epileptics were received into this establishment during these periods, and that, making all due allowance for any conjectural change in the type or inveteracy of alienation in different stages of our civilisation, the recoveries were what at present are achieved and what may possibly be a normal ratio. But in 1820 there is a sudden augmentation in the number of recoveries, for a physician of high repute affirms that the cures of persons in his asylum reached the unprecedented amount of 91 percent, of recent cases, 35 of chronic cases, and 81 of all classes, even including the idiotic, the epileptic, and the fatuous. About the same time a popular writer of travels returned from a distant land with the somewhat startling intelligence that he had obtained irrefragable proof that 91 and three-tenths per cent, of cures had been effected under an experienced physician. Housed from passiveness or apathy to vaulting ambition, every Englishspeaking psychologist exerted his skill and?we must use the phrase?his ingenuity, in producing tables displaying what were conceived to be the triumphs of his art. Insanity became, in the eyes of the philanthropist, the most curable of formidable diseases, and, if taken during its earlier state and subjected to suitable remedies, must be cured, either by the efforts of *
Burrow's Commentaries. g
2
84
THE
CURABILITY OF INSANITY.
or, as therapeutic agents were not then more potent infallible than now, must cure itself. It became a race, a struggle, a strife for distinction, and statistics exhibited a sudden rush upwards from the modest success of Tyson to the astounding maximum of 100, even 110, per cent. In the present day, when these gigantic proportions have shrunk to a more moderate size, it is almost inexplicable, in passing the eye over the long lines of figures and percentages, to conjecture how such conclusions could be arrived at. A superintendent, whose subsequent eminence is said to have entitled him to the title of Pinel Secundus, announced that he had restored to reason lunatics at the rate of 100 per cent. It should be carefully noted that this success applied to 13 patients only, one of whom died. Another expert reached the number quoted by Burrows, and even the calm and cautious Tuke, of the Retreat, averred that, according to his observation, there were curable, of recent cases 91 per cent., of old cases 35 per cent., of all cases 81 per cent. From other records we find that while, one superintendent can still boast of 100 per cent., a second falls to 99, a third oscillates between 82 and 94, a fourth has a variable rate from 82 to 93, a fifth reached 91, a sixth gives 80 to 90, while a seventh, a most honest and eminent historian of his own practice, inserts in his earlier chapters 80 per cent., but as the narrative proceeds, his success, or rather the mode upon which that success was computed, undergoes a signal alteration. It is incumbent here to protest that there is not the faintest insinuation as to the motives or the faithfulness under which such results are supposed to be arrived at. The explanation of the discrepancy which exists between past and present experience upon this point is to be sought for in the vicious or erroneous principles upon which these supposed facts are founded. In the first place, recoveries were estimated in reference to acute or recent cases only, such words signifying very different things and periods according to the convictions Instead of limiting recovery of acute cases of the recorder. to three months previous to admission, it might represent one year, and was, under all circumstances, indefinite and arbitrary. In the second place, the number of recoveries In the third was calculated on the number of discharges. and all chronic all incurable, epileptic, paralytic, place, idiotic cases, and even all deaths, were deducted from the gross numbers which were or had been under treatment, before the recoveries were dealt with; and these might then be compared with the admissions, the discharges, or even with the residuum still remaining in the asylum. It would be an insult to our existing convictions and to the principles, which may be
medicine, or
THE
CURABILITY
OF
INSANITY.
85
the estimates of the results diseases to point out how utterly fallacious, deceptive, and Utopian were such practices ; but it is essential to our object to stigmatise them as subversive, on the one hand, of all correct notions as to prognosis in mental disease, and, upon the other, of the remedial powers which can be exercised for its removal or amelioration. In instituting any comparison between the results in different establishments, and in endeavouring to reconcile the palpable disparity between these which is conspicuous, various factors of restoration, as well as impediments to such an issue, must be embraced, as they intimately affect the general inquiry as to the duration and removal of alienation. Allusion has already been made to the influence of peculiarly constituted minds upon conclusions as to the present or potential benefit to the insane derived from medical interference ; but the actual benefits differ independently altogether from the opinions of the expert in different countries and classes, in relation to the profession or trade of the patient, to the average amount of intelligence and education prevailing in the district, to the immorality or intemperance or irreligion of which each individual may have been a victim, and to his original capacity and subsequent development. It is well known that where imbeciles? and there are communities of imbeciles?are attacked by delirium or excitement, that, in the rare instances of transitory mania? and we use the word advisedly and without any intention of entering on a qucestio vexata?and where mutual disturbance originates in poisons, not alcoholic, but generated in the system, such as in the urine, bile, &c., the continuance of the nervous ailment is brief, its removal of easy accomplishment, and the apparent rate of recovery is thus augmented. Where mental or moral epidemics occur this remark is especially applicable, and there is good reason for believing that not only do the seasons materially influence the cessation or promote the chronicity of the neurosis, but that these affections are more amenable to the resources of art at one time?for example, The experience of Tyson in one century?than in another. has already been quoted, showing that between 1684 and 1703 of 1,294 patients admitted into Bethlehem, 890 recovered, while in the same institution, where still only recent, curable, or non-paralytic cases are received, between 1846 and 1855 of 2,729 patients admitted, 1,479 recovered (Hood). Making all due allowance for a change in the type of disease, the discrepant opinions of medical superintendents, and the revolution insensibly taking place in the views of the medical profession generally, a more striking illustration is afforded by the following
now
pronounced catholic, regulating
of treatment in
nervous
86
THE
CURABILITY
OF
INSANITY.
embraced was from September 30, 1868, In 1871 Dr. X resigned. Dr. W succeeded him in the superintendentship of the game asylum. The last three entire official years of the administration of Dr. X embraced the period from September 30, 1868, to October 1, 1871, and the first three of Dr. W, the period from September 30, 1872, to October 1, 1875. The statistics of these periods show that, during the first period, of 1,191 admissions 516 recovered, 43*32 per cent., and that, during the second, of 1,169 or admitted 269 recovered, or 22*16 per cent. Thus, although the number of admissions in the second period was but twentytwo less than in the first, the number of recoveries was but one We are not permitted even to suspect more than half as great. that any other feeling than legitimate professional rivalry could have actuated these labourers in the same field. Nor is even this conjecture admissible, as a marked declension in the fruits of the cultivation during the last harvest described is discernible. This comparative view is taken from the records of a public asylum, and in such alone is competition intelligible. Upon this ground it is desirable that the effects of treatment in private asylums under the management of trained and trustworthy medical experts?and there are many such?could be ascertained, as the very ungenerous argument that this class have a vested pecuniary interest in the detention of the persons consigned to their care must operate in preventing premature discharges, and many of the evils which may flow from a strain after public notoriety and the creation of an artificial reputation for the skill and success of the medical authorities. As next in reliability, may be ranged the recoveries in our public asylums, where the determination of the fact is arrived at by an educated responsible officer, who, although perhaps less or more influenced contrast.
The
to October
period
1, 1875.
by disturbing, though unconscious, sources of fallacy and error, acts according to the dictates of a deliberate judgment, and under the criticism of a vast jury composed of associates and fellow labourers. Such deliverances almost invariably vindicate the foregoing remarks as to the absence of uniformity in the effects of treatment; whether the disparity displayed be in the product of a difference in the standard employed, or in the perspicacity or imagination of the observer employing it, is not now discussed. For example, taking the annual reports of five large British public asylums for 1879, it appears that the percentage of cures ranges through 25, 33,40,41, 47 per cent. But it is highly probable that, at the present time, as when ThurIn round numbers, of ten persons attacked by nam wrote, insanity five recover and five die, sooner or later, during the "
attack.
Of the five who recover, not
more
than two remain
A
TIIE
CURABILITY OF INSANITY.
87
during the rest of their lives. The other three sustain subsequent attacks, during which at least two of them die." Such estimates are unavoidably formed at the moment of the discharge of the patient and based upon the most trustworthy evidence accessible. These, although in one sense oracular, and the mere opinion of one person, must be accepted as data of great authority, seeing that the opinion thus emitted represents the prolonged observation and criticism of a scientific and conscientious expert, who, while he may be deceived by theories or hopes, cannot be suspected of deceiving others. But when it is known that in many institutions the emphatic declaration of discharged cured, and all its concomitant and consequent relations to psychological inquiry, is pronounced by a board of county gentlemen, who may, or may not, be guided by the convictions of their subordinates in the management of the house, it is natural to recoil from the perplexing confusion which may thus arise as to the absolute reality and degrees of the curability of the insane. It is well known that in many asylums, before the removal of an inmate to his house, there must be an appearance before the directors, so that the report of the superintendent, as well as the health, capacity, self-control of the postulant, may be tested, and, as is generally the case, This practice may prove a confirmed by the bureaucracy. guide and a guarantee to the public, but is neither complimentary to medical discrimination or honesty, nor conducive to accuracy in speculation on the progress and termination of disease. The board supposed to be thus engaged generally consists of men of high birth, ample education, unimpeachable integrity, and unselfish feelings, so that their deliberations and verdict are entitled to perfect respect, although they cannot be hailed as truths of Holy Writ or as scientific conclusions. But when such a body is composed of parish guardians, or, what is equivalent in Scotland, the parochial board, and when the members, whose honesty of purpose we do not here call in question, may be the butcher, baker, undertaker, &c. of the village, borough, or union?who, unless inspired, cannot possess any of the qualities which enable the observer to judge of the mental condition, either in health or in disease, of any individual; and who, whatever may be their humanity and sympathy, and their independence of spirit, cannot fail to be influenced by the selfish, or they may be honourably designated, the social and patriotic interests of their constituents?it is difficult to avoid a smile, or a shudder, over the havoc which may accrue to medical statistics, and the injuries which may be reflected upon families
well
and communities as well as the individual under examination. But such fiat may depend upon the impressions of a single
88
THE
CURABILITY OF INSANITY.
observer?the relieving officer in one country, the inspector of poor in another?who are constrained to act in accordance with their brief, or their own very partial information. When liberation is effected by a family council, or by the decision of friends, who have no opportunity of watching the peculiarities of their cloistered relatives, and who are animated by a natural and justifiable anxiety to promote the well-being of the person in whom they are interested, and to secure the supposed advantages of freedom, home, and original pursuits and pleasures, the risks of such interference are greatly multiplied, and to this source may be attributed the majority of the relapses which crowd the columns of the register of every public institution. But the inmates of such establishments, particularly where they belong to the affluent ranks, may be removed from treatment in a number of other ways. They may be dismissed by the authority of medical, legal, or official assessors, of high national or public functionaries, acting with or without advice, with or without any explanation of the grounds on which action has been taken, of the objects proposed, and, it has happened, in direct opposition to the experience and warnings of those who have cared for and scrutinised the symptoms, and have arrived at well-digested opinions ds to the probabilities of perfect and permanent restoration to health. But into the possible mistakes or misdoings of these possessors of power I hesitate at present to enter.
From this vidimus, which is, unfortunately, far from exI have endeavoured to exclude all considerations of self-interest and pecuniary gain, because I believe that such unworthy incentives are of rare occurrence, and cannot materially affect speculations as to the ultimate issues of mental diseases. In compliance with what is almost the universal custom of those who have been engaged in exposing abuses, errors, and the miscarriages of philosophy and philanthropy, I would very humbly venture to suggest, as a means of preventing or lessening the evil complained of, the creation of a corps of experts, as has been proposed for other purposes, and which might be incorporated with the Board of Commissioners, or who might be constituted from properly qualified medical men, upon whose judgment and decision alone, in conjunction with those of the ordinary hospital superintendent, should depend the liberation of every patient. It is incumbent to acknowledge my indebtedness to a " pamphlet on The Curability of Insanity," by Dr. Pliny Earle, Northampton, Massachusetts, for many facts in this article.
haustive,
