Chapters in the History of the Insane in the British Isles Part 34

Rather must we rest satisfied with the general advance in treatment in a scientific direction. Most of us know asylums where, within forty years and much less, tartarized antimony was in daily use in large doses as a quietus, and where croton oil was administered in addition to black draughts to a surprising extent, all these remedies being now employed only on the rarest occasions. Take an actual example, one of many, in a particular asylum. A few years ago a patient, who had been much excited and very troublesome, was treated in season and out of season with strong purgatives and sedatives. It so happened that he then fell under a new _regime_, which consisted in knocking off all these medicines and placing him under one attendant's entire supervision. The result was that he became as quiet and docile, though not cured, as any of the inmates of the asylum, and has remained so to the present time. But we may go further, and say that some cases of insanity are cured now which a few years ago would have remained uncured. Indeed, in relation to the a.s.sociated bodily state, it may be said that specific treatment has been adopted. Remedies, like iodide of pota.s.sium, in large doses, are employed in cases in which, from the increased attention directed in recent years to the somatic aetiology of insanity, a causal relation between the physical and mental condition has been recognized, and the mental symptoms have disappeared in the most marked manner; and so again in gouty melancholia, relief has been obtained by appropriate remedies and diet. These are ill.u.s.trations of the directly scientific application of medicine to medical psychology, and it is in this direction we must hope for a really satisfactory advance.

On the other hand, there are the successes obtained by the employment of drugs without our being able to say why or how they have exerted a curative agency; and it is obvious that as the number of drugs has so much increased during the period over which my survey extends, the chances of hitting on the right remedy are proportionately increased.

How often we see one, two, or three drugs exhibited in mania without any result, while a fourth acts like a charm. Only by studying in detail the special characteristics of each case, can we hope to find a clue which will serve as a guide to the treatment of a subsequent one.

In this country, Dr. Clouston has distinctly advanced our knowledge of the action and uses of narcotic remedies by experiments made to determine the effect on maniacal excitement of single doses of certain remedies, stimulants, and food; of, again, the effect on mania of prolonged courses of certain narcotic medicines, along with clinical observations on the effects of the same medicines in all kinds of insanity, and has determined the equivalent value of opium, bromide of pota.s.sium, and cannabis indica in the treatment of insanity.

Dr. Savage has experimented with one drug at a time on a number of patients, and has already given to the profession some valuable results in "Guy's Hospital Reports," and the _Journal of Mental Science_. "The West Riding Asylum Medical Reports" of Dr. Crichton Browne also contain some important experiments with drugs by himself and others; and in this connection I would notice the excellent clinical notes issued from time to time by Dr. Williams and other officers of the Haywards Heath Asylum, which are well worthy of more permanent record in the archives of the a.s.sociation. I cannot, indeed, understand any one seriously maintaining that we are practically no better off in our medicinal resources now than we were forty years ago.

Whatever differences of opinion may exist in regard to the advantages gained by the introduction of new drugs, one thing is clear, that the employment and, let me add, the repose of patients, well-ordered arrangements, and the tact of the superintendent will oftentimes do more to reduce the amount of excitement and noise in an asylum than tons of chloral and bromide. For example, any one who has visited Hanwell knows that Dr. Rayner antic.i.p.ates and prevents post-epileptic mania to a very large extent by the simple expedient of keeping patients in bed after their fits, just as he finds forced alimentation of patients rarely necessary when rest is resorted to. It is striking to see how, even in an over-grown asylum and an old building, the results of good management and treatment can be highly satisfactory, and worthy of an inst.i.tution of such historic fame.

But, after all, the question faces us, are there or are there not more insane persons cured in 1881 than in 1841?

One's first impulse, of course, is to take the statistics of recovery for a certain number of the more recent, and compare them with those of the earlier years, or to take the recoveries of the past forty and place them side by side with those of the previous forty years. The attempt, however, is fraught with so many fallacies that it is dangerous to make such a comparison. In a report of Bethlem Hospital, issued in 1841, Sir Alexander Morison stated--not as anything exceptional--that seventy per cent. of the patients had been discharged cured; while an examination of the recoveries at this hospital for the last ten years shows a much smaller proportion per cent. But I cannot accept these comparisons as proving anything one way or the other, as various causes, quite apart from the comparative success of treatment at different periods, may explain the difference. Take a single asylum, like Hanwell, and compare the recoveries of a later with an earlier period. I find a population so fluctuating in character, in regard to curability, that the comparison becomes utterly worthless, and although it is true that during the last quinquennium 28.1 per cent. have recovered, as against 26.3 per cent.

during the first quinquennium of the past forty years, in spite of there having been more incurables received during the later period, the result is not so satisfactory when we divide into certain periods the whole time during which Hanwell has been open (omitting the first four years).

It then appears that during two previous periods the recoveries were higher than 28.1 per cent., viz. from 1840 to 1849 and from 1865 to 1874. Thus:--

1835-39 (inclusive) 25.3 1840-49 28.5 1850-54 25.2 1855-64 27.9 1865-74 30.4 1875-79 26.3

Or in quinquennial periods throughout:--

1835-39 (inclusive) 24.8 1840-44 26.3 1845-49 32.1 1850-54 25.2 1855-59 30.7 1860-64 27.0 1865-69 30.4 1870-74 30.5 1875-79 26.3

If to escape the fallacies connected with the comparison of different periods of the same asylum, we go to the Lunacy Blue Books, we do not get any reliable figures before 1870, on account of transfers having been previously included in the admissions, so that a fair comparison of recent and former recoveries worked on the admissions is impossible.

I have before me the statistics of the Siegburg Asylum, thanks to Dr.

Ripping, from its opening to its close; and I find that the recoveries during the first twenty-five years amounted to forty-two per cent., and during the twenty-five years ending with the year 1877, they were forty-six per cent., thus showing an increase of four per cent. in the more recent period. As this asylum, now closed, has admitted curable cases only, these figures are among the few valuable statistics which I have been able to procure.

I have not succeeded in obtaining satisfactory comparative results by adopting, in the mixed asylums of England and Wales, the plan of working the recoveries, not on the total admissions, but on those only deemed curable; but to explain this fully would involve me in more detail than the occasion warrants.

I would add that in the United States, where reasons have been a.s.signed why the statistics of asylums exhibit apparently fewer recoveries in the later than the earlier period of the last forty years, Dr. Pliny Earle has done good service by the remarkable contribution he has made to the question of the curability of insanity,[312] corroborating, at the same time, the somewhat unfavourable conclusion as to permanent recovery which Dr. Thurnam, in a work which will always be a Pharos to guide those who sail on waters where so many are s.h.i.+pwrecked, arrived at, after a laborious examination of the after history of cases discharged recovered from the York Retreat. It is likewise anything but rea.s.suring to find that, out of the total number of lunatics under care in England and Wales, there are at this moment only 3592 who are deemed curable.[313]

Such, gentlemen, is my Retrospect of the Past. Meagre it has necessarily been, though occupying more of your time than I could have wished, but the number of subjects demanding reference must be my excuse.

We found, at the commencement of the period we have traversed, the accommodation provided for the insane scandalously insufficient, and the condition of many of the existing asylums calling loudly for a radical reform.

We witness to-day, throughout the kingdom, a large number of inst.i.tutions in admirable working order, reflecting the greatest credit upon their superintendents and committees.

We found a wholly inadequate system of inspection.

We witness now a Board of Commissioners, which, without forfeiting the good will of the superintendents, carefully inspects the asylums throughout the provinces as well as the metropolis--as carefully and thoroughly, at any rate, as the same number of men originally appointed to examine into the condition of some 20,000 patients can fulfil a like duty for above 70,000.

We found a resolute attempt being made to carry out and extend the humane system of treatment inaugurated nearly half a century before in France and England.

To-day we witness its success.

And had I had time to sketch the progress in the provision made for criminal lunatics, we should have found that just forty years ago was the commencement of what Dr. Nicolson has named the "Reactionary Period"--during which this a.s.sociation pet.i.tioned the Government (in 1851) to establish a criminal lunatic asylum--followed in 1860 by the "Period of Centralization" or that of Broadmoor--an inst.i.tution to-day so efficiently superintended by Dr. Orange.

And in what consists the superiority of the new over the old system of treatment--the nineteenth over the eighteenth century?

The old system was mainly one of brute force--the child alike of ignorance and fear.

The new does not indeed dispense with force, but it is a maxim of the reformed school, from which no one, whose opinion carries weight in psychological medicine, whether in America or in Europe, would dissent, that it should be reduced to the lowest possible point, consistent with safety and the good of the patient, and that humanity should dictate the means of repressing, or rather guarding against, violence, both as regards their amount and character.

The old system subjected patients, who underwent any medical treatment at all, to a miserable routine, often determined by the season of the year and the phases of the moon, rather than the condition of the patient.

The new does not pretend to possess a universal formula, or to have discovered the psychologist's stone, but strives to treat each patient according to individual indications.

The old system desired secrecy; the new is not afraid of publicity.

The old system, in short, believed in harshness and darkness; the creed of the new is, "I believe in sweetness and light."

Such are the results achieved for Psychological Medicine.

If this be the Retrospect of the Past, what is the Prospect of the Future? Will the progress of the last forty or the last ninety years be maintained? I trust it will, but one need not be a pessimist to be sensible that the humane treatment of the insane may have its ebb as well as its flow; that so far from its being true that there is a constant and certain tendency to humanity, there is also a strange tendency to relapse into inhuman ways. Vigilance is and always will be required, for if it be allowed to slumber, we but too well know that there is only one direction in which things will go when left to themselves--and that is downhill.

The functions--the mission--of this a.s.sociation may be regarded from a threefold point of view: first, in relation to insanity and the insane; secondly, in relation to its members; thirdly, in relation to the public.

I.--Under the first are comprised what in the original rules, drawn up by the founders of this a.s.sociation forty years ago, were stated to be its objects, namely, "Improvement in the management of asylums and the treatment of the insane;" and further, "The acquirement of a more extensive and more correct knowledge of insanity."

Added to the improved management of asylums is the necessity now for making appropriate provision for idiots and imbeciles, and their education so far as practicable, grappling at the same time with the problem how best to provide for the ma.s.s of incurable pauper patients in the provinces, and the extension of middle-cla.s.s asylums, and of cottages in connection with the central inst.i.tution.

There are, of course, various ways in which the welfare of the patients in asylums can be promoted, by the attention directed by the a.s.sociation to special points of importance. To instance only one, the occupation of patients, including systematic teaching which Dr. Lalor has so successfully developed in the Richmond Asylum, Dublin. Though very much has been done, there is, all, I think, will agree, room for more sustained effort in this direction. "There is one monster in the world--the idle man," are the words of one who has lately pa.s.sed beyond the reach of praise or blame, which ought ever to be in the minds of those who direct our asylums. It may be that if more were done in future in the spirit of this apophthegm of the Sage, if not the Saint, of Chelsea, there would be less chance of patients chewing the cud of bitter reflection and dwelling upon the delusions by which they are haunted and hara.s.sed.

In proportion as we feel the inadequacy of our means of cure, we must recognize the necessity of studying the aetiology of insanity, including that _d.a.m.nosa haereditas_, which is the cause of causes in so large a number of the cases coming under our treatment. But what induced the ancestral taint? It behoves us to pay more and more attention to those laws of inheritance in general to which Mr. Hutchinson has recently directed attention in his suggestive lectures at the College of Surgeons.

When M. Baillarger proposed that a similar a.s.sociation to this should be established in France, he gave, among other reasons, the advantage which would accrue from discussing this very question. "Every one," he said, "is a.s.suredly decided upon the influence of heredity in the production of insanity (Mr. Buckle had not then written); but in this primary question, how many secondary ones there are which remain unsolved."

Since he thus wrote, his own countrymen, Morel and Lucas, have, by their researches, advanced our knowledge, and rendered the task of their successors in the same field easier.

Intemperance also, as a cause as distinct from a symptom of insanity, requires to be more thoroughly examined into, and I am happy to say Dr.

Hayes Newington, than whom no one could be better fitted for the task, has prepared a series of questions arranged in a tabular form, which has been before the Statistical Committee, and will appear in the _Journal_.

Again, there remains for the future the continued research into the causal connection between certain mental symptoms or disorders and accompanying lesions of the brain and cord. Dr. Spitzka, of New York, in the prize essay which he is about to publish, enters carefully into this inquiry, and I am hopeful that his industry and talent will be rewarded by marked success. These and kindred investigations might, no doubt, be pursued in a more methodical manner than is always the case in English asylums. To this end, the appointment of a pathologist, as at Wakefield in our own country, and at the Utica Asylum in America, ought to become general.

Clinical teaching in our asylums admits of much greater development, though they may not be able to meet the demands made upon them, should examinations be required in medical psychology by the examining bodies.

To-day the student has fortunately a very different position from that which fell to his lot forty years ago. He has at his command means of research then unknown, as the ophthalmoscope and sphygmograph, and all the modern improvements in the microscope and in preparing sections; and can he not experiment on knee jerks, and a host of reflex and electric phenomena never dreamt of by his predecessors? He has, moreover, the stimulus begotten of the sense that enough has been discovered to indicate how much precious treasure lies hidden beneath the ground he now treads, like the gold-digger whose ardour is quickened and labour repaid by the discovery of the minutest particle of the metal of which he is in search.

II. The second relation in which this a.s.sociation stands--to its members--suggests that we must needs be alive to legislation affecting the rights of those who are engaged in this department of medicine. This a.s.sociation is not a trades union, but there are various points bearing on their position which have to be considered, as in connection with a Bill like Mr. Dillwyn's, or the matters discussed two years ago at the annual meeting, when brought forward by Dr. Murray Lindsay. It is true that for him who has taken mental science, in its widest sense, as his mistress; for him who has wooed her for her own sake, knowing full well that for him she may hold no dowry in hand or pocket, there is the supreme pleasure arising from study and observation themselves--that recompense which is better than gold, and more precious than rubies. All this is true; but none the less the superintendents of asylums have a right to expect not only that their services shall be adequately remunerated when in harness, but that they may count with certainty upon a fair provision in the evening of life.

III. With regard, thirdly, to the influence of this a.s.sociation on public opinion, we should be strangely faithless to our mission, if we were not the expositors of the principles in accordance with which the insane ought to be regarded; if we did not endeavour to enlighten the community in the doctrines of true psychological science, and in that philanthropy which is as far asunder as the poles from the fitful pseudo-philanthropy from which our country is unfortunately not free, the wild, ill-regulated, hysterical clamour with which we are epidemically visited, as injurious to the lunatic as it is to the interests of society at large.

This a.s.sociation, further, ought to continue to bring before the lawyer what it regards as the just test of criminal responsibility; to entreat the educator not to defeat the object of his n.o.ble profession by exactions which transgress the limits by which Nature has bounded human capacity; and to warn parents, as Dr. Brigham did in his day with so much zeal, of the dangers to mental health arising from precocious forcing during the early growth of the brain, and with a tenfold greater necessity than when he wrote, in presence of the illimitable folly of examining boards, some of them medical, the members of which have not even the poor excuse of ignorance; and last, but not least, to counsel the teacher of religion against the peculiar dangers which attend his exalted mission, remembering that--

"Virtue itself turns vice, being misapplied."