^ THE \ 3) LIBRARIES Z^ HEALTH SCIENCES LIBRARY /J ft - Cipldemlo Digitized by tine Internet Archive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/curabilityofinsaOOearl c^edicine ^ Society In o^merica cyJfedicine ^ i^ociety In G^merica Advisory Editor Charles E. Rosenberg Professor of History University of Pennsylvania THE Curability of Insanity: A SERIES OF STUDIES BY PLINY EARLE, A.M., M.D. m qArno ^ress & The A^w York Times New York 1972 Reprint Edition 1972 by Arno Press Inc. LC# 70-180573 ISBN 0-405-03949-2 Medicine and Society in America ISBN for complete set: 0-405-03930-1 See last pages of this volume for titles. Manufactured in the United States of America THE Curability of Insanity: A SERIES OF STUDIES. BY PLINY EAELE, A.M., M.D., LATE STIPEEIXTENIIENT OF THE STATE LUNATIC HOSPITAL AT KOETHAirPTON, MASS. ; EX-PEESIDENT OF THE ASSOCIATION OF 3IEDICA1 STPEEISTEN-DENTS OF AilEEICAN IXSTITUTIOXS FOE THE IXSAXE; PEESIDEN'T OF THE NEW ENGLAND PSYCHOLOGICAL SOCIETY; HONOEARY IIEJIBER OF THE BEITISH MEDICO-PSYCHOLOGICAL ASSOCIATION ; COEEESPONDING MEIIBEE OF THE NEW YOEK JIEDICO-LEGAL SOCIETY, AND OF THE MEDICAL SOCIETY AT ATHENS, GREECE ; MEMBER OF THE A3IERICAN PHILO- SOPHICAL SOCIETY ; OF THE SOCIAL SCIENCE ASSOCIATION, ETC. " One principle may be suiBcient to guide you, — that of standing rigorously by tbe fact, however naked it look." — Thojias Caelyle. PHILADELPHIA : J. B. LIPPIJ^COTT COMPAXY. 1887. Copyright, 1886, by Pliny Earle. PREFACE. It is now nearly ten years since my essay — "The Curability of Insanity," enlarged from the original in the annual report for the official year 1875-76 of the Northampton Lunatic Hospital — was read before the New England Pyschological Society, and published, by direction of that association, in pamphlet form. Mean- while, seven other articles upon the same subject have been embodied in my annual reports to the trustees of the aforesaid institution. Those papers have been favor- ably received by a large number of readers, both at home and abroad. It is not presumptuous to claim that they have greatly modified the aspect of insanity, as a curable mental condition, in the view of a large pro- portion of the persons most interested in the subject. They have thus been an important agent in stimulating the minds of philanthropists to seek — and in several notable instances to adopt — other methods for the cus- tody and care of a large part of the insane than that of collecting them in expensive and unwieldy curative institutions. They have caused a very important change in the statistical methods of Massachusetts, in this 3 '4 PEEFACE. country, and Great Britain in Europe, whereby the reader is informed of the number of persons, as well as of patients, or cases, that recover. This more nearly perfect method will undoubtedly gradually find its way to other States and countries, until it becomes universal. Under these circumstances, hoping that they may still be beneficial in the directions indicated, and by the ex- pressed desire of some of the leaders in the great work of public charity and beneficence in this country, I have here brought those papers together, in a form convenient for preservation, perusal, and reference. The book, as a book, is simply what it is represented to be in its title, — "A series of Studies," — each of them essentially, or to a great extent, independent of the others. It consequently follows that any criticism of it on the assumption, either expressed or implied, that it is, or that it professes to be, a well-digested, logically-constructed monograph, would be unjust, and hence worthy of deprecation. Some of the repetition, which, in the original publica- tion, was a necessary consequence of several discussions of one and the same subject, has here been avoided ; and it is hoped that no more of it remains than is necessary effectively to impress upon the mind of the reader the points which are intended to be illustrated or enforced by it. RE. August 28, 1886. TABLE OF CONTENTS. STUDY FIEST (written in 1876) : Chapter I. — Introductory .... Chapter II. — History — The Extremists Chapter III. — History — Opponents . Chapter IY. — History — Other Authorities. Chapter V.— The Ebbing Tide . Chapter YI. — Curability in all Hospital Cases Chapter YII. — Deductions .... Chapter YIII. — Conclusion STUDY SECOND (written in 1877) . STUDY THIED (written in 1878) . STUDY FOUETH (written in 1879) STUDY FIFTH (written in 1880) . STUDY SIXTH (written in 1881) . STUDY SBYENTH (written in 1882) STUDY EIGHTH (written in 1885) . 7 18 31 34 46 52 56 61 64 83 103 140 159 176 196 THE CURABILITY OF INSANITY. STUDY KIRST. (WRITTEN IN 1876.) CHAPTER I. INTRODUCTORY. Within the last few years, calculations have been made, in more than one of the States, for the purpose of showing the pecuniary loss that has accrued to those States, respectively, from a failure to cure that portion of their dependent insane assumed to have been curable in the early stages of the disease. In Pennsylvania, the calculation was made by the Board of Public Charities, and is based upon the estimated number that became insane in the decennium from 1864 to 1873, inclusive. The author of it assumes, upon what he considers un- questionable authority, that seventy-five per cent, of them, if jDroperly and seasonably treated, might have been permanently restored to health and usefulness. Had this been done, the total cost of treatment, together with the support, for life, of the twenty-five per cent. uncured, would, according to his estimate, have been 7 8 THE CUKABILITY OF INSANITY. only $6,540,066. On the contrary, had all these patients been placed in poor-houses, where it is assumed that seven per cent, of them would recover, the cost of support, during life, would have been |1 1,271,932. " This," says the writer, " shows a clear saving of |4,731,866." He then proceeds to show that, if the seventy-five per cent, had been cured, their earnings would have amounted to $4,945,000 more than they would if only seven per cent, had been cured. Adding these sums he obtains a total of $9,676,866, " a gain," he says, " of that much to the wealth and power of the community." Having completed the calculation, he says, " we urge a very careful attention to, and also criticism of the above demonstration." But a few months have elapsed since, in an official report of the Commissioner of Insanity in Vermont, it was alleged, as a condemnatory fact against the hospital for the insane of that State, that the proportion of re- coveries among the patients has recently been less than it was in the earlier history of that institution. In view of this allegation, and of the main proposition of the foregoing paragraph, it has appeared to me that a re- view of the subject of the curability of insanity might not be wholly useless at the present time. The ''demonstration," a criticism of which is invited by the Board of Public Charities of Pennsylvania, will not suffer, as an intellectual process, either in its logic or its mathematics, from the closest scrutiny. The serious question in regard to it is, are the elements of the calculation true ? If either of them be false, the de- duction from them cannot be otherwise than untrue. Although not directly so stated, it is evident that the seventy-five per cent, of assumed curables relates to THE CURABILITY OF INSANITY. 9 'persons, and not to cases ; that is, that the author of the ^''demonstration" believed, or appears to have believed, that three-fourths of all the men and women who be- come insane can be permanently cured. The truth of this assumption is necessary to the truth of the deduc- tion at which he arrives. The belief that mental disorders are thus largely curable is not entertained by the Board of Public Charities of Pennsylvania alone. It has become pretty widely prevalent among persons interested in the sub- ject of insanity, but not, themselves, engaged in the treatment of the insane. Some of these persons enter- tain the opinion that even a still larger proportion are susceptible of cure. It is one of the objects of this paper to ascertain, if possible, whether this opinion is justified by the facts. As an almost, if not entirely, universal rule, the superintendents of the institutions for the insane report the recoveries of cases rather than of persons. A person may be admitted more than once into a hospital, and hence make as many cases as the number of his admis- sions. As a case he may recover several times; and not only so, but, after several recoveries, he may still die insane. His history then furnishes to the statistics of insanity several recoveries of cases but not one per- manent recovery of a person. Thus, at the State Hos- pital at Northampton, a man was discharged, recovered, seven times, and improved, once, in the course of nine years; and subsequently committed suicide at home. Another man has been discharged, recovered, six times, on the same number of admissions, in the course of fifteen years. One woman was discharged, recovered, 2 10 THE CURABILITY OF IISTSANITY. eight times on as many admissions, in the course of eleven years. Another, admitted six times in the course of nine years, was discharged recovered every time ; and a third, admitted six times within a period of eight years, was likewise discharged, recovered, every time. These five persons have, as cases, recovered thirty-three times, and yet it is not probable that either of the per- sons has permanently recovered. Every institution for the insane has its cases of this kind, and, as a rule, the older the institution the more it has of them, and the larger is the number of times that each of them has been discharged recovered. The most remarkable instance of the kind which has come to my knowledge occurred at the Bloomingdale Asy- lum, New York, where a woman was admitted fifty- nine times in the course of twenty-nine years, and was discharged, recovered, forty-six times. Dr. Joshua H. Worthington, Superintendent of the Friends' Asylum at Fraiikford, Pennsylvania, informs me that eighty-seven persons have contributed two hundred and seventy-four recoveries to the statistics of that institution, an average of a fraction more than three to each person. One patient recovered fifteen times ; another thirteen ; a third nine ; a fourth eight ; and a fifth seven. Those statistics are indebted to those five persons for fifty-two recoveries, or an average of ten to each person. So, while the uninformed reader be- lieves that fifty-two persons recovered, the^ truth of the matter is that no less than three of the persons died insane in the asylum, and consequently the permanent cures, if any, could not, at most, have been but two. The report for the official year 1867-68, of the Re- THE CUKABILITY OF INSANITY. 11 treat at Hartford, Connecticut, contains a table by which it is shown that, of the 4898 cases admitted, thitherto, into that institution, only 3062 were of first admission. In other words, there were but 3062 persons, 707 of whom were readmitted once or more, making a total of 1836 readmissions. Hence, of each hundred of patients received, thirty-seven (37.48) had been there before. One person was admitted thirteen times, and thirteen persons were admitted a total of one hundred and eight times. How many of those one hundred and eight times the thirteen persons were discharged recovered, the report does not inform us ; but we may reasonably conclude that it was a large majority. Yet, which of those persons was really cured ? At the Pennsylvania Hospital for the Insane, of 7167 admissions recorded in the report for 1875, only 5186 were cases of first attack. No less than 1981 were of attacks subsequent to the first. One man was admitted on the twenty-second attack, and one woman on the thirty-third; six men and six women on the tenth attack ; ninety-four persons on the fifth attack ; and one hundred and seventy-two persons on the fourth. Dr. Kirkbride does not state the number. of times that any of these had recovered ; but if a person have a thirty- third attach of a disease, it necessarily follows that he had previously recovered from thirty-two attacks. Dr. Barnard D. Eastman, of the State Hospital at Wor- cester, is now engaged in an analysis of the cases treated at that institution from the time of its origin. The work was begun upon the cases of females, about one-half of which have been passed under review. I am indebted to him for some of the results thus far attained. 12 THE CURABILITY OF INSANITY. Of 2949 admissions, 694 were readmissions. Hence, 2255 persons constituted 2949 patients. The readmis- sions were equal to nearly one-third (30.80 per cent.) of the persons. Seven persons were admitted an aggregate of one hundred and six times, or an average of a fraction more than fifteen times each. One was admitted twenty- three times, one eighteen times, one sixteen, one four- teen, one thirteen, and two, eleven times each. One of the seven persons was discharged recovered twenty-two times, one sixteen times, one thirteen times, two eleven times each, one ten times, and one nine times. Conse- quently, the seven persons furnished ninety-two recov- eries, or an average of a fraction more than thirteen recoveries to each person ; and yet two of these persons died insane in the hospital, and a third is now an inmate of it, considered hopelessly insane. Thus, of the ninety- two recoveries presented to the readers of the Worcester reports, the permanent recoveries of persons were, at most, only four.^ Such is the chaff which, for a long period, the people of Massachusetts have been accus- tomed to regard as the kernel of the wheat. Very ap- propriately has Dr. Sheppard, of the Colney Hatch Asylum, England, remarked, " It is obviously one * Since the above was written, I have learned that, of these four persons, one was again readmitted at the "Worcester Hospital, January 10, 1877. The second, since last at Worcester, has been discharged, improved, twice, from the Butler Hospital, at Provi- dence, Ehode Island, and, during the last seven years, has been a constant inmate of that hospital, incurably insane. The third '•died at home, years ago, mental state not known;" and the fourth " probably died at home, circumstances unknown." THE CUE ABILITY OF INSANITY. 13 thing to formulate error, and another to formulate truth." What further revelations may be made in the prosecution of Dr. Eastman's enterprise, time alone can show; but, even should there be none of noteworthy- importance, he may be well satisfied with these, as a full reward for his labor. These cases of multij^le admission and recovery some- times materially affect the proportion of apparent cures for the year, as represented by the annual reports, in consequence of a resort to the hos]3ital several times within the year of one of those cases of periodical mania, the duration of the paroxysms of which are very brief. Soon after I became connected with the Bloomingdale Asylum, in 1844, I learned that the woman who was the subject of the remarkable case above mentioned had been admitted and discharged, recovered, six times within the next preceding year. In the course of 1844 she was again received and discharged, recovered, six times. Following the example of my predecessor, I reported these recoveries in the tabulated statistics without any textual explanation. In the next following year, 1845, the woman was admitted and discharged, recovered, four times. In the annual report for that year, all the cases of readmission were mentioned, and their results given separately. There were eleven readmissions and seven recoveries ; and in the context it was stated that " four of the cures mentioned in this table were restorations from succes- sive attacks, in a case of paroxysmal mania." This case subsequently led to the introduction of the question of the proper method of reporting jDeriodical cases, as a subject for discussion at one of the meetings of the 14 THE CURABILITY OF INSANITY. Association of American Superintendents. After due consideration it was decided that no patient ought to be reported as recovered twice or more within one and the same year. It is evident, however, that this de- cision has not been universally, probably not generally, apparently not in a single instance, adopted as a rule of practice at the hospitals. As proof of this, in regard to one institution, we have the case of the woman who recovered twenty-two times at the Worcester Hospital, as shown by Dr. Eastman's statistics. Four of her recoveries took place in one year. Jive in the next fol- lowing year, and seven in the third year. Worcester, therefore, takes the palm from the brow of Bloomingdale, for the largest number of recoveries by one person within the course of twelve successive months. In this case, the woman, within a period of twenty years and two months, recovered twenty-two times, and spent eleven years and one month in the hospital. In all the foregoing instances, as in many others which might be gathered from hosj^ital reports, the percentage of recoveries is very considerably increased by this duplication and multiplication of them in the same per- son ; and yet, by the way in which they are generally published, the uninitiated reader has no reason even to suspect that the number of persons recovered is not equal to the number of recoveries. Aside from the repeated admissions and recoveries of the same person, there is another influence which has an important effect upon the projoortionate reported restoration of mental disorders. I allude to the special characteristics of the person reporting them, — his tem- THE CUEABILITY OF INSANITY. 15 peramentj his constitutional organization, his psycholog- ical individuality. How often we find the people of a neighborhood differing in opinion in regard to a neighbor alleged to be insane ! How frequently the superintendents of the hospitals are annoyed by persons holding this difference of oj)inion in regard to patients committed to their care, one party strongly asserting the existence of mental disorder, the other as strongly denying it ! In the trial, before legal tribunals, of cases involving the question of the sanity or insanity of a prisoner or other person, it is not uncommon for even the most expert experts to differ in both opinion and testimony, taking opposite views of the mental condition in question. In a case like this, it is to be inferred that if, when that testimony is given, the person whose mental condition is in ques- tion were to be discharged from a hospital to which he had been committed wlien unquestionably insane, the experts u^oon one side would report him recovered, while those upon the other would record him as not recovered. The individuality mentioned has sometimes, though rarely, been recognized and acknowledged in the reports emanating from the institutions for the insane. ''It has come to be well understood among those familiar with vital statistics," says Dr. D. Tilden Brown, of the Bloomingdale Asylum, New York, in his report for 1867, "that they comprise an element not easily discovered among groups of figures, but which is, never- theless, jDresent as a leaven more or less potent. Bor- rowing a term from physiology, this element'^' may be Xow called "the personal equation." 16 THE CURABILITY OF INSANITY. called the ' reflex action' of the observer's own temper- ament, and no just estimate of such statistics can be formed, until its value can be approximately deter- mined." For many years I have believed, and have often asserted that belief, that of a given number of patients discharged from a hospital for the insane, the number reported as recovered might differ at least twenty-five per cent., according to the man who might act as judge of their mental condition. The medical history of the Worcester hospital, during the seven years next preceding the 1st of October, 1875, furnishes a remarkable illustration of tlie uncertainty of the statistics of insanity, as originating in the source under consideration. From September 30, 1868, to October 1, 1875, there was no known agency operating upon the people from whom the patients of that hospital are drawn, which might either increase or diminish the prevalence of in- sanity, or so modify it as to render it less amenable to curative treatment. About the middle of the period a change of superintendents of the institution took place. Dr. Bemis resigned the ofiice, and was succeeded by Dr. Eastman. This occurred within the official year 1871-72, so that each of those gentlemen occupied the office during a part of that year. The last three entire official years of the adminis- tration of Dr. Bemis embraced the period from Sep- tember 30, 1868, to October 1, 1871; and the first three of Dr. Eastman, the period from September 30, 1872, to October 1, 1875. The statistics of admis- sions and recoveries in the course of each of these THE CUKABILITY OF INSANITY. 17 periods, as derived from the published reports, are as follows : FIEST PEKIOD. Official Year. 1868-69. 1869-70. 1870-71. 387 384 470 Total I 1191 Kecoveries. 149 158 209 516 Per cent, of Recoveries. 44.21 41.11 44.46 43.32 SECOND PEKIOD. Official Year. Admissions. Recoveries. Per cent, of Recoveries. 1872-73 1873-74 1874-75 - 407 400 862 98 71 90 24.08 17.75 24.86 Total.. 1169 259 22.16 Thus, although the number of admissions (1169) in the second period was but twenty-two less than (1191) in the first, the number of recoveries (259) was but one more than half as great. The proportion of recoveries of the first period is to the proportion of recoveries of the second, as 195 to 100, or as 100 to 51.15. There is, in my opinion, but one explanation of this most surprising difference ; and that is, the difference in the physical and mental constitution of the two men by whom these statistics were reported. Were it possible to apply to the two sets of cases a standard of sanity and an accurate measure of mentality, it would doubt- less be found that there were as many recoveries in the second period as there were in the first. In the ex- pression of this opinion I desire to be emphatic, as I 18 THE CUEABILITY OF INSANITY. have too high a respect for both of the gentlemen con- cerned to do or say anything which might be tortured into the appearance of injustice toward either of them. There are yet other modifying agents which have "un- doubtedly acted, to some extent, in the production of the statistics of insanity, as they have in so many other departments and directions of the enterprise of mankind. The medical officers of institutions for the insane can claim no exemjDtion from the common weaknesses of human nature. They are men " with like passions as other men." Self-interest, in some instances, and ambi- tion in perhaps all, — that ambition, at least, which is manifest in the desire to show as fair a record and as favorable results as are exhibited by colleagues in the specialty, — have probably not been wholly inoperative in the reporting of recoveries from insanity, even though unconsciously to the persons producing those reports. These influences have constituted, and, from the very nature of things, always must constitute, an element in the solution of the problem of the curability of mental disorders. CHAPTER 11. HISTOEY. THE EXTREMISTS. Of all the causes which have contributed to the pro- duction of the impression that insanity yields to curative treatment in a larger ratio than is now believed by physicians best acquainted with the subject and having THE CUKABILITY OF USTSANITY. 19 the largest practical experience, the most potent has been the frequently repeated assertions of their eminent curability, by the superintendents of hospitals, and by some other writers upon the subject. In proof of this proposition, it is proposed to present a cursory history of the subject during the last fifty or sixty years, with quotations of such evidence as the annals of the period may furnish. In the year 1820, Dr. George Man Burrows, of Lon- don, England, published a small work entitled "An Inquiry into certain Errors relative to Insanity," one object of which was to demonstrate that mental dis- orders are more curable than was at that time generally supposed. He therein asserts that, of all the cases which had been treated by him, both in general prac- tice and injiis private asylum, " including patients in a state of fatuity, idiocy, and epilepsy, the proportion of recoveries was 81 in 100 ; of recent cases, 91 in 100 ; of old cases, 35 in 100." He admits that he had " been much favored by an unusually large proportion of recent cases ;" and in his " Commentaries," published eight years afterwards, he acknowledges that his percentage of cures " appeared by some to be doubted." Dr. Burrows had treated only 296 cases, not half so many as are to-day under the care of Dr. Godding, at Taunton. Of the 242 recent cases, 221 recovered, and of the 54 old cases, 19 recovered. In the appendix to the " Inquiry," the doctor pub- lished the statistics of the recoveries at the Betreat, at York, from 1796 to 1819. These were furnished by Samuel Tuke, and were classified according to the dura- tion of the mental disorder. Thev are as follows : .. 20 THE CURABILITY OF INSANITY. Cases. Duration. Attack. Kecov- ered. Per Cent. 47 45 34 48 79 Le.ss than three months Three to twelve months Under twelve months First 40 25 21 12 14 85.10 55.55 61.76 25.00 17.72 First Not the first First Hence are derived the further statistics that, of the 92 cases of first attack, and of less than one year in duration, the recoveries were 6o, or a proportion of 70.65 per cent. Of all the cases (126) of less duration than one year, whether of first or subsequent attack, the re- coveries (86) were equal to 68.25 per cent. The ratio of recoveries of the whole number treated was 44.26 per cent. The next authority to which our attention is called is the annual report of the Retreat, at Hartford, Con- necticut, for the oflftcial year 1826-27. The information contained in that report " fell upon dry and stony ground," and doubtless Avould have there remained, fruitless and comparatively unknown, had it not been gathered and disseminated by a travelling foreigner. Captain Basil Hall, of the Royal Navy of Great Britain, visited the Retreat on the 25th of October, 1827, and gave an account of that visit in the history of his American tour, which was subsequently published.* "Dr. Todd," says the captain (vol. ii. p. 192), "the eminent and kind physician in charge of the Retreat, gladly communicated his plans, and showed us over * "Travels in North America, in the yearvS 1827 and 1828," by Captain Basil Hall, Eoyal Navy. In three volumes. Edinburgh, 1829. THE CUE ABILITY OF INSA]!«^ITY. 21 every part of this noble establishment, — a model, I venture to say, from which any country might take instruction." Upon subsequent pages he copies " ex- tracts from the report of the visiting physicians," one of which is as follows : " During the last year there have been admitted twenty-three recent cases, of which twenty-one recovered, a number equivalent to 91.3 j)er cent. The whole number of recent cases in the institution during the year was twenty-eight, of which twenty-five have recovered, equal to 89.2 per cent."* Thus recognized and endorsed, not merely in Great Britain, but by a representative of that arm of her power in which has hitherto rested her confidence, as the source of her greatest pride and glory, the " report of the visiting physicians" suddenly became worthy of recognition upon this side of the Atlantic. The news- papers took it up and sent it through the length and the breadth of the land ; and in this way, whatever a few physicians and others might have previously learned from the report itself, the people at large received their first impression that insanity is largely curable. By a 'few strokes of his magic pen Captain Hall did what, were it not for him, would have required the labor of years. Very soon after the appearance of this book in the United States, and while the memory of the Hartford statistics was still fresh and vivid, Massachusetts caused to be erected her first State hospital for the insane, at \ Worcester. It was opened in January, 1833. Dr. ^ Vol. ii. page 196. 22 THE CURABILITY OF INSANITY. Samuel B. Woodward, its first superintendent, came directly from the atmosphere of the Hartford Retreat. That institution was in part indebted to him for its existence. He was one of the few who took the initia- tory measures for its foundation ; he was one of the original directors to whom its charter was granted ; and its welfare had always been to him an object of interest and solicitude. Dr. Woodward's intellectual abilities were consider- ably above the average. He was cheerful and sanguine, and much interested in his specialty, which he conse- quently pursued with enthusiasm and entire dedication of time and thought and feeling. Both his j)hysical temperament and his intellectual constitution were such as not only to induce, but perhaps to force him to " look upon the bright side of things," whatever might call for his opinion or action. A man so constituted, having such antecedents and the reported success at Hartford as an example, would not be likely to present the subject of insanity, as it appeared at Worcester, in a less cheerful light than nature and truth would justify. In his second annual report, which embraced the official year terminating with the 30th of September, 1834, he wrote as follows, in his summary of the statistics of the year : " Recov- ered, of all the recent cases discharged, eighty-two and one-quarter per cent." The reader will please observe that this high percentage represents the ratio of recov- eries to cases discharged, and not to cases admitted. It is believed that a non-observance of this fact, by the casual or the careless reader, was one cause of the erroneous impression conveyed to the public mind. THE CTJKABILITY OF INSANITY. 23 In his third report the doctor says, "Recoveries of those patients during the year ending JSTovember 30, 1835, whose insanity was less than one year's duration, eighty-two and one-half per cent. ;" and, upon another page, "In recent cases of insanity, under judicious treatment, as large a proportion of recoveries will take place as from any other acute disease of equal se- verity." It is believed that this was the first public annunciation, in America, of the principal idea of the proposition contained in the quotation, — namely, the curability of insanity as compared with other severe acute diseases. In the fourth report, for 1836, he says, " Per cent, of recoveries of recent cases discharged, eighty-four and one-fifth ;" and in the fifth, for 1837, " Per cent, (of recoveries) of recent cases discharged of less than one year's duration, eighty-nine and one-fifth." Whatever erroneous idea may have, thus far, been inadvertently and unintentionally produced by the method of computing the proportion of recoveries upon the number discharged, it ought to have been corrected by the subjoined extract from the report for 1838, in which the language would imply that it is computed upon the number admitted : " There have been admitted, since the hospital was opened, three hundred and thirty-four cases of less duration than one year ; of which, two hundred and seventy-six have recovered, which is about eighty-two and two-thirds per cent. " In most institutions, it is customary to deduct those that have not had sufiicient time ; this may be said of the twenty-eight recent cases left in the hospital at the 24 THE CURABILITY OF INSANITY. end of the year ; these deducted, the per cent, of recov- eries will be ninety and one-half. "If we make a further deduction of the deaths of the cases from this class, which is also the rule in many institutions, we should increase the per cent, to about ninety-four." Although apparently avoiding the erroneous method of computation before mentioned, this extract well illus- trates the prevalent desire of the time at which it was written to produce enormous percentages of recoveries. That both reason and common sense were sacrificed to that desire, is sufficiently proved by not this quotation alone, but by others, from other sources, yet to be pro- duced. In the second jDaragraph of the above extract, the reader is asked to reject all cases remaining in the hospital, although unquestionably a considerable part of them were incurable ; and, as if this were not enough, he is then, in the third paragraph, invited to set aside all who have died ! If, in calculating the curability of mental disorders, all cases of mortality are to be rejected, why not in all other diseases? The principle appears as reasonably applicable in pneumonia or typhoid fever as in insanity, but it is a principle better adapted to the consolation of the physician than to the discovery of truth in science. Let it be applied, for example, to consumption and Asiatic cholera: calculate the percentage of recoveries accordingly, and behold what harmless diseases they immediately become ! In the seventh report of the hospital at Worcester, the proportion of recoveries, for the year, of recent cases discharged, was asserted to be 90 per cent. ; in the THE CURABILITY OF INSANITY. 25 eighth, sixty-four patients of seventy, equal to 91.42 per cent. ; and in the ninth, 91 per cent. This was in the latter part of the year 1841. " The average of re- coveries of cases of less duration than one year," says this report, "is now 88 per cent, for the whole time (nine years), and is as great as can be expected." When Dr. Woodward took charge of the hospital at Worcester, there were but eight other institutions, spe- cially devoted to the care and custody of the insane, in the United States. Four of them were incorporated, and only three — in Virginia, South Carolina, and Ken- tucky — belonged to the States, respectively, within which they are situated. Of a majority, at least, of the eight, the chief medical officer was merely a visiting physician engaged in general practice. Annual reports were published by but a part of them ; and such as were published were brief, and their circulation very limited. Thus circumstanced, there was a golden op- portunity for the doctor to disseminate among the peo- ple some knowledge of insanity and its treatment in hospitals, and thus give an impetus to the thitherto languid and lagging enterprise for the amelioration of the condition of the insane upon this side of the Atlan- tic. This opportunity he did not fail to seize. His very elaborate reports, abounding in statistics, as well as in other matter more attractive to the general reader, were widely circulated, and he soon became known, not only throughout the States, but likewise in Europe, and was generally regarded as the highest living American authority in the treatment of mental disorders. In the course of the ten years next following his removal to Worcester, no less than twelve hospitals for the insane 3 ■26 THE CURABILITY OF INSANITY. were founded and opened within tlie States, and seven of them, were State institutions. The superintendents of some of these were men of no less abihty than Dr. Woodward, and they entered heartily into the prosecu- tion of their work. Some of the older institutions, meanwhile, had become newly and ably officered. Dr. Bell had taken charge of the McLean Asylum, and Dr. Brigham of the Hartford Ketreat. A s^^irit of emula- tion was aroused, which, at length, by stimulation, be- came what might more properly be termed rivalry, albeit the generous rivalry of friends, and conducted, as a whole, in the love of science and under the prompt- ings of benevolence. We are now approaching the maximum mathematical curability of insanity. The next foregoing paragraph is considered important, as showing some of the causes which led to it. In 1840, the Worcester Hospital had attained, as shown above, a proportion of 91.42 per cent., and in 1841, 91 per cent. The percentage of Dr. Burrows, as has been seen, was 91. In the report of the Eastern Asylum for the Insane, in Williamsburg, Virginia, for the year 1842, Dr. John M. Gait, the superintendent at the time, quoted the per- centages of recent cases claimed to have been cured by Sir William Ellis,* Dr. Burrows, Dr. Woodward, and, on the authority of Basil Hall, the Retreat at Hartford. He then gave a statistical account of thirteen cases of * In his treatise on insanity, published in 1838, Dr. Ellis does not discuss the subject of curability. Probably this claim, " about ninety per cent.," was made in a report of either the AVakefield or the Hanwell Asylum, with both of which he was, at different times, connected. THE CURABILITY OF INSANITY. 27 recent insanity received at the institution under his charge, iu the course of the year from July, 1841, to July, 1842. Six months after the expiration of that year, twelve of them, equal to 92,3 per cent., had recovered, and one had died. The doctor describes this single case of mortality, and then, adopting that admirable principle of exclusion, the j^recedent for which, in this country at least, had been established by Dr. Woodward, says, "If we deduct this case from those under treatment, the recoveries will amount to 100 per cent. !" " From such facts as the above," he continues, " I am led to believe that there is no insane institution, either on the Continent of Europe, in Great Britain, or in America, in which such success is met with as in our own." The considerate reader will forbear to arraign the doctor for a deficiency of modesty. He had excelled his colleagues in the work of benevolence, and who but he could make it known ? He had produced the thitherto maximum of percentage figures, including deaths; nay, more, had he not, under a recognized jDrinciple, mathematically demonstrated the curability of one hundred per cent., that is, all of the insane? Lest the living may not reply to this interrogation, I call upon the dead. What says Dr. Bell, of the McLean Asylum, thereupon, — Dr. Luther V. Bell, than whom, in the United States of America, no abler man, intel- lectually, and no more conscientious man, morally, has ever been engaged in the specialty of psychology ? "The records of this (McLean) Asylum," says he, in his report for the year 1840, "justify the declaration that all cases J certainly recent, — that is, whose origin does not, either directly or obscurely, run back more 28 THE CURABILITY OF INSANITY. than a year, — recover under a fair trial. This is the general law; the occasional instances to the contrary are the exception." These things sound so very strange at the present day, that, in order to reassure the reader, it would appear proper to inform him that no instance is recol- lected, and none, at the time of the present writing, has been discovered in the books, in which the claim to have cured more than one hundred per cent., or even that more than one hundred per cent, are curable, has been advanced. Logically, perhaps, claims of that nature might have been made; because the foregoing extracts from Gait, Bell, and Woodward were written more than thirty years ago, and some of the writers of the present day apparently believe that great improve- ments have been made in the treatment of insanity since that time. Although the spring-tide of mathematical curability had now apparently attained its highest point, and Dr. Gait was upon the crest of its topmost wave, — with Dr. Bell beside him in opiniative curability, for Dr. Bell entertained an inveterate dislike of the Arabic numerals as applied to insanity, — yet a further change was in reservation in the undeveloped but still immediate future. In only one short year after the recounted success at Williamsburg, Dr. Awl — there was a proph- ecy even in the sound of his name — in his report, for 1843, of the State Hospital for the Insane at Columbus, Ohio, thus unpretentiously but pithily announced his achievement for the year : " Per cent, of recoveries on all recent cases discharged the present year, 100." And so the goal was won ; the THE CURABILITY OF INSANITY. 29 summit of the maximum wave of the highest possible high- water point was gained ! Dr. Awl, who had " stud- ied at the feet of Gamaliel" (Dr. Woodward), and who was always his loyal disciple, had outrivalled, not his master alone, but all other competitors. But Dr. Woodward, in his report for the same year (1843), wrote as follows : " I think it not too much to assume that insanity, un- connected with such complications (epilepsy, paralysis, or general prostration of health) , is more* curable than any other disease of equal severity ; more likely to be cured than intermittent fever, pneumonia, or rheumatism." Dr. Bell's report for the same year contains a general review of all the cases, "somewhat exceeding a thou- sand," which he had treated during his connection with the McLean Asylum, in which he says, " The best judgment I can form is, that six out of every ten dis- charged, including those considered unfit, those dis- charged with incomplete trial, and those dying prior to the event being determined, have recovered." Of those cases the duration of which was less than six months at the time of admission, he says, " Certainly nine- tenths have recovered." After the Ohio triumph of 1843, there were indica- tions, in some quarters, of an ebbing of the tide. Dr. Woodward, indeed, in his report for 1844, reported the recoveries of recent cases, at Worcester, at 93 per cent., and thus excelled his former self; but in that for 1845, his thirteenth and last, this percentage receded to 89.50. Dr. Chandler succeeded Dr. Woodward, and in his re- *jSrot italicized in the oriirinal. 30 THE CURABILITY OF INSANITY. port for 1846 the retrograde movement was still greater than in the next preceding year, the proportion of re- coveries of recent cases being but 79 per cent. This recession, however, was subsequently in part recovered from, and during the ten years' administration of Dr. Chandler the average was 83 ])eY cent., whereas during the whole period of Dr. Woodward's administration it was 88 per cent. Even Dr. Awl never again equalled himself. The prophecy was never fulfilled but once. In 1844 his percentage of recoveries of recent cases discharged re- ceded to 89.47 ; but in 1845 it mounted to 95.12, and in 1846 to 95.38. In 1847 it again receded, and, this time, to 88.44; but only to remount, in 1848, to 90.36; and in 1849, as shown by his eleventh and last report, to 93.25. In this re23ort he states that the " per cent, of recoveries on all recent cases discharged in eleven years, was 90.70." The reader will observe that all these pro- portions related to cases discharged, and his attention i^ called to the comments upon them, by Dr. AwFs succes- sor, as presented upon a subsequent page. But Dr. Awl was content with the permission to his numerals to speak for themselves. In this he was al- most purely a statistician in Arabic. So far as I have learned, he neither vaunted his success, nor proclaimed the pre-eminent curability of insanity, in the text of his rej^orts. Ardent, hopeful, joyful in temperament, he naturally presented his subject in a light sufficiently couleur de rose ; but, for the same reason, he endeared himself to his colleagues, of whom every survivor would now exclaim, " May his genial heart still beat for a thousand years." THE CURABILITY OF INSANITY. 31 CHAPTER III. HISTORY. OPPONENTS. He would be mistaken who should entertain the be- lief that, throughout this period of apparent struggle for the largest numerical symbols, there was a unanim- ity of opinion and feeling among the medical superin- tendents of the institutions. Yet, whatsoever might have been thought, or in conversation expressed upon the subject, but little, if anything, appeared in the pub- lished reports discrediting either the asserted results of treatment, or the accuracy of the method by which the numerical statistics were obtained. Dr. Isaac Ray, in the report^ for 1842 of the State Asylum at Augusta, Maine, wrote as follows : " Nothing can be made more deceptive than statistics ; and I have yet to learn that those of insanity form any exception to the general rule." But the first important shadow of this kind which was thrown upon the glamour of Arabic num- bers was projected by Dr. James Bates, a man of ster- ling common sense, the successor of Dr. Ray. In his report for 1847-48 he used the following language : "Few things are nioi'e various, in the numerous re- ports which come to hand from institutions similar to our own, than what are termed recent cases. In gen- eral, of late years, cases admitted within one year of the attack are denominated recent. This would be very well, and easily understood, if such cases were continued 32 THE CURABILITY OF INSANITY. to be recent cases, in the reports, until discharged. But such is not the fact. In one report which contained a table purporting to give the admissions and discharges of recent and old cases, it was seen that the recoveries, discharges, and deaths, together with recent cases re- maining, were much less than stated in the admissions. Further examination showed that at the end of each year those remaining in hospital which had become of more than one year's standing, were turned over to the department of old cases.* " By such a course, and rejecting deaths, paralytic alid epileptic cases, and perhaps some others, from the aggregate, the cures of recent cases are very conveniently carried up to ninety per cent. "It is probable, in some instances, this rejection and pruning away of exceptionable cases might be carried so far that one hundred per cent, of recoveries in recent cases could be reported, and received with wondrous admiration by that portion of the public who are better * The practice mentioned may be illustrated as follows : A hospital receives one hundred recent cases, and reports them as such. It discharges eighty of them ic^i'de recent ; and, of these eight}', seventy have recovered. Consequentl}^, seven-eighths, or eighty-seven and one-half per cent, of the number discharged^ are reported as recovered. The remaining twent}^ of the original one hundred stay in the hospital so long that their disease has existed more than a year, and hence is no longer recent. They are then transferred to chronic cases, and thenceforth, in all sta- tistics relating to them, are reported as such. It is thus made to ajipear that of the original one hundred cases, eighty-seven and one-half per cent, recovered, when, in fact, only seventy per cent, recovered. There was a time at which this practice Avas pursued at more than one hospital. THE CURABILITY OF INSANITY. 33 pleased with marvellous fiction than with homely truth." Not satisfied with this, he again expressed his opin- ions, and perhajos more strongly, when discussing the subject of statistics, in his report for 1849-50. Says he, — " When honestly made, they are not likely to do in- jury ; but I am sure they are sometimes made the instruments of deception. If figures cannot lie, they may mislead by disguising the truth. For instance : suppose, at the end of each year, instead of reporting all cases as recent which were actually admitted within one year of the attack, I should, for the purpose of appear- ing to cure ninety per cent, of recent cases discharged, report only such as recent cases as had not become old ones by remaining with us, I might impose the belief on the uninitiated that ninety per cent, of recent cases could be cured, when every man acquainted with the subject knows that no instance can be shown in which ninety out of one hundred cases, admitted in succession, no matter how rectnt, were ever cured." About this time Dr. S. Hanbury Smith, a man of broad culture and extensive professional knowledge, was appointed to the superintendence of the State Asylum for the Insane at Columbus, Ohio. In his report for 1850 he presents the statistics of all the recent cases of insanity received at that institution, from the time of its opening to the 30th of November of that year; and shows that the recoveries, according to the records, and including those remaining in the hospital who were be- lieved curable, were equal to 75.43 per cent. "The curability of recent cases in this institution," he then 34 THE CUEABILITY OF I]!^SA]SriTY. remarks, "would be exactly represented by these fig- ures, were it certain that the word recovered, when en- tered opposite a name on the books of the institution, is always properly employed. The term has probably been applied to many cases which were only very much improved, but not in scientific strictness cured, seventy j)er cent, being considered by some authorities as about the limit of possible cures in recent cases." Dr. Andrew McFarland's first report of the New Hampshire Asylum for the Insane was for the year 1846. He classified the cases of both admission and discharge into recent and chronic, but calculated no percentage. In his third report (for 1848) he dropped that classification and gave expression to his views in the following language : " This is deemed a proper time and place to record a scejDticism as to the value of a system of forming tables, or rather the want of system, in makilig impor- tant deductions, and establishing infallible percentages from extremely loose and insufiicient premises, and all now engaged in the treatment of the insane appear to be arriving at the same conclusion." CHAPTEE IV. HISTORY. OTHER AUTHORITIES. The period of greatest mathematical curability had now very evidently passed ; that spring-tide upon which the members of the regatta had been disporting for a THE CURABILITY OF IISTSAlSriTY. 35 number, not inconsiderable, of years, had begun to ebb, and has continued to ebb, as will be shown farther on, to the present time, when it has reached, perhaps, upon the average, very nearly the true water level. At this point, however, it may still further elucidate our subject to show the position in regard to it which was occupied by several medical superintendents in charge of institutions during some part of the period of high percentages, but of whom little or nothing has thus far been written. Dr. Kay, at heart, never approved the course of the advocates of mathematical curability. Upon his en- trance into the s^^ecialty it is not surprising that he joined them, but he did it under protest, and at the very first opportunity he threw off all allegiance to them. In his first report, which was that for the Maine Insane Asylum for the year 1841, he classified his cases into recent and old, the former term applying to those of less than one year in duration. " I have adopted this classification," says he, " in deference to the practice now somewhat common in New England hospitals; but I must be allowed to express my conviction that the dis- tinction is without any precise, well-marked difierence, ^nd had better be abandoned." In giving the results of treatment, he says, " Per cent, of recoveries of recent cases discharged in the course of the year, 71 ;" and then, in a foot-note, he re- marks as follows : " Two of the recent cases discharged uncured were returned to the hospital and finally dis- charged, cured; so that really the per cent, of recov- eries of recent patients is 75." In another place he 36 THE CURABILITY OF INSANITY. says, " Our proportion of recoveries in recent cases, as indicated by our books, has been 71 per cent., though, if we make allowance for cases prematurely removed, it amounts to 85 per cent., which is the average of recov- eries obtained in the New England hospitals generally." Dr. Ray never built a percentage a second time, in the hope to make his mathematical house as high as those of his neighbors. Thenceforward, both at the Maine Asylum and at the Butler Hospital, he discarded classification according to duration, eschewed percent- ages, and, especially at the institution last mentioned, dealt but little in other numerical statistics. Dr. Amariah Brigham wrote but two annual reports of the Hartford Retreat. The last of these is the only one to which I have access. It is for the official year ending with the 31st of March, 1842. Before the termi- nation of that calendar year he was appointed to the superintendence of the New York State Asylum, at Utica, which was opened, under his direction, on the 16th day of January, 1843. In the report of the Re- treat he says, " The records of this, and of all kindred institutions, establish the fact that insanity is a disease that can generally be cured, if early and properly treated ; while it is equally well established that if the disease is neglected, or suffered to continue for two or three years, it is rarely remedied. In his first report (for 1843) at Utica, he says, "Eighty patients have been discharged. Fifty-six of these were recent cases, that is, of not more than twelve months' duration. Of this number, forty-nine recovered." The percentage of these recoveries is not stated, and neither in the report of the Retreat, nor any one of the six annual rej^orts THE CURABILITY OF HSrSAlSTITY. 37 which he lived to write at Utica, have I found any such percentage. He did not classify his cases in tabular form, as recent and chronic, and the instance just quoted is the only one in which, as regards recovery, he mentioned the numbers with such a discrimination. He was not a competitor in the regatta of mathematical curability. But in this connection, and as a matter illustrative of our subject, I copy the following from his last report for the Retreat : " By recovered, we usually mean complete restoration of the mental powers. Two of the individuals dis- charged this year, and reported as recovered, are still very eccentric, though they do not now manifest any- thing that their friends call insanity, are able to attend to their affairs, and are as well as they were for several years before they were called insane. " Some few other individuals, though reported recov- ered, did not, when they left us, exhibit their former mental vigor. From several of these we have heard that, at home, they have entirely recovered in this re- spect, or are steadily improving. With these few excep- tions, those that we have reported recovered we consider completely so." If limitations so comprehensive were given to the term " recovered" by a nfioderado, like Dr. Brigham, what might not be granted to it by an ultraist, such as were some of the medical superintendents ? In the annual presentation of the medical history of the Pennsylvania Hospital for the Insane, Dr. Thomas S. Kirkbride has very prudently and properly avoided the classification of patients according to the duration v^f the disease; and, although apparently a believer in 88 THE CURABILITY OF INSAI^ITY. the curability of insanity to an extent which would not be accorded by a large proportion of the superinten- dents of the present day, he has never been among the extremists, has written but little upon that specific point, and has invariably, I believe, shunned percentages in Arabic numerals. In an examination of his first fif- teen annual reports, I find but two allusions to the curability of the disease, of sufiicient directness and im- portance to come within the scope of this discussion. In the report for 1842 he says, " The general proposi- tion that truly recent cases of insanity are commonly very curable, and that chronic ones are only occasion- ally so, may be considered as fully established." In the report for 1846 the proposition is made rather more definite by the use of a |)ercentage — perhaps the only one to be found in his reports — expressed in words. " Of all who are attacked with insanity, and subjected during its early stages to a judicious treat- ment, and that treatment faithfully persevered in, at least eighty per cent, will probably recover." In his report for 1844, of the Bloomingdale Asylum, New York, the first which was issued after he became connected with it. Dr. Pliny Earle presented a table of " cases supposed to be recent," in which it is stated that the number discharged was fifty, of which forty-five had recovered. Nothing was said of percentage in regard to them ; but the subjoined extract is taken from the context : " It appears to be very satisfactorily proved that, of cases in which there is no eccentricity or constitutional weakness of intellect, and when the proper remedial measures are adojDted in the early stages of the disorder. THE CUEABILITY OF INSANITY. 39 no less than eighty of every hundred are cured. There are but few diseases from which so large a percentage of the persons attacked are restored." In his report for 1845, the table of recent cases states that of fifty-seven cases discharged, thirty-six were cured ; and in connection therewith, it is remarked that four others, " discharged much improved, were entirely well a short time after they left. These make the num- ber of cures in recent cases forty T In a discussion of the subject of treatment, in the same report, occurs the following proposition : " When the insane are placed under jDroper curative treatment in the early stages of the disease, from seventy-five to ninety per cent, recover." The author of those reports deprecates, in regard to these extracts, no comment which he has here applied to the same assertions, or assertions equally strong, but no stronger, by any one of his colleagues. But, thirty- two years ago, Dr. Earle was somewhat younger than he is now, and had not had the benefit of so extensive an experience. His practical knowledge of the treat- ment of insanity, at that time, had been derived from -a number of cases very considerably less than that of those who are under his care to-day. He has had time, and opportunity, and reason to modify many of his opinions ; and among those modified opinions is that of the curability of insanity. Doubtless there are others of the writers here quoted who would now seek protection, and who deserve it, under a similar plea. The reports of Dr. William H. Kockwell, of the Vermont Insane Asylum, were models of sententious brevity. Their author indulged sparingly in numerical 40 THE CURABILITY OF INSANITY. statistics, but lie always gave the percentages of recover- ies calculated upon the number of j^atients discharged, and with unvarying discrimination between " old cases" and "recent cases." The percentages of the recent cases always ranked among the highest, but only in one instance did they exceed ninety. This was in 1839, when the percentage was 91.33. In all the other years from 1838 to 1845, inclusive, they fluctuated between the two extremes, 87.50 and 89.74, In his report for 1849, in connection with a summary of all the patients theretofore treated at the institution, it is stated that, " of those placed at the asylum within six months from their attack, nearly nine-tenths have recovered." Dr. William H. Stokes, in the report for 1845 of the Mount Hope institution at l^altimore, Maryland, dis- coursed as follows : " In our former reports, for 1843 and 1844, we as- sumed the high ground that not merely nine out of ten cases of insanity, of a less duration than one year, may be cured, but that ninety-nine in a hundred can be radically restored, unless there exists in the individual a strong constitutional tendency to mental disease, or unless circumstances beyond our control, and the in- jurious tendency of which has been fully explained, intervene to interrupt and disturb the process of cure. This position has been fully sustained, as the report will show, by the experience of the past year." In respect to this quotation, it may be remarked that, while the proposition may be strictly true, as inter- preted by an expert of long experience, yet the popu- lar reader would be likely to remember the large pro- THE CUEABILITY OF USTSANITY. 41 portions in its assertive clause, while forgetting, or rather not knowing, the broad scope of the contingent clause, as introduced by the word unless. These con- tingencies have, since that time, practically proved their power in the very great reduction of the assumed pro- portions. Ninety-nine cases in a hundred of any disease may be cured, unless something prevents. In the report for 1841 of the Western Lunatic Asy- lum, at Staunton, Virginia, Dr. Francis T. Stribling, a most estimable man and an excellent superintendent, introduced a numerical table to which he appended these remarks : '' From this table it will be perceived that the whole number of recent cases during the year, in which an opportunity has been afforded to test the use of medi- cines, amounts only to twenty-one, of whom eleven were males, and ten females. Of these, seventeen recovered, nine males and eight females ; two females are improved, one male is stationary, and one male died. From this estimate is excluded, of course, those patients who en- tered the institution within the last twenty days, as their stay has been of too short duration for the effects of remedies to be develojDcd. The individual above included as having died, was only here sixteen days, and for the same reason should also be excluded, which would leave as proper subjects for this table twenty only, of whom eighty-five per cent, have recovered, a result which we confidently believe will bear honorable comparison with that in any other insane institution in existence, and one which should speak trumpet-tongued to those misguided individuals who, notwithstanding the lights which have been shed upon this important subject 4 •42 - THE CURABILITY OF INSANITY. within a few years past, obstinately persevere in retain- ing their insane friends at home, or in situations equally unfavorable, until their malady becomes confirmed and they are rendered, for life, the victims of insanity, it may be, in some one of its most aggravated and dis- tressing forms." His report for 1844 contained, in tabular form, the number of recent cases admitted from July 1, 1836, to December 31, 1844, together with the results of treat- ment and the percentage of those results. The recov- eries, as calculated upon the admissions, were equal to eighty-two, and as calculated upon the discharges, ninety- three per cent. Of writers other than the medical superintendents, there is but one the opinions of whom it appears neces- sary liere to notice. Several years ago. Dr. Edward Jarvis wrote as follows : "In a perfect state of things, where the best appli- ances which the science and skill of the age have pro- vided for healing are brought to bear upon these luna- tics in as early a stage of their malady as they are to those who are attacked with fever or dysentery, prob- ably eighty, and possibly ninety per cent., would be restored, and only twenty, or perhaps ten per cent., would be left among the constant insane population." To the superficial reader, particularly if he be young and enthusiastic, this reads well, appears full of prom- ise, and may be received as the assertion of a positive proposition in scientific truth. The thoughtful reader finds it too heavily laden with the conditional, the doubtful, and the impossible. " Go to the foot of the THE CURABILITY OF INSANITY. 43 rainbow" — how often it was heard, and how it excited our admiration in boyhood! — "and you will find a golden cup." " In a perfect state of things," the writer might better have said, " there would be no insanity," for that would have been a positive truth. The "per- fect state of things" which he fancied, is unattainable, and consequently the whole substance of the proposi- tion is little better than speculation. It is utterly impossible, and so will it continue to be throughout all time, unless the characteristics of insan- ity undergo very important changes, to subject the insane to curative treatment at as early a stage of their disorder as are persons seized with fever or dysentery. In a very material proportion of the cases — more than ten, and, in my opinion, more than twenty per cent. — the approach of the malady is so slow and insidious that the insanity is not recognized, often not suspected, until it has passed the period in which it might have been amenable to appropriate treatment. Hence, prac- tically, it is chronic and incurable from the beginning. To this class belong all cases of paresis — the paralysie generale of the French — as well as those in which natural peculiarities or eccentricities gradually increase with advancing years, until they become so exaggerated as to be generally and properly accepted as the mani- festations of insanity ; those in which the brain and the nervous system in general succumb, hopelessly and somewhat suddenly, to the accumulated deleterious effects of intemperance in intoxicating drinks and of other forms of dissipation; and those of "spoiled children" who, by the results of unwise management during the perio^ls of youth and adolescence, become 44 THE CURABILITY OF INSANITY. some of the annoyances, jpar excellence, of the hospitals. There are other cases still, but it is unnecessary here to mention them. The last clauses of the proposition quoted from Dr. Jarvis, those which express the deduction or the se- quence of the conditional premises, are deprived of force by the assertion of a " probability" and a " possi- bility," instead of a certainty. But, as has been shown, the certainty has not been, and it cannot be, demonstrated. At most, then, the quotation, strictly interpreted, signifies that by the performance of an impossibility, you may arrive at a probability or a possibility. But very much to my surprise, and, as I apprehend, to that of every person of long and large experience with the insane. Dr. Jarvis has quite recently repeated his proposition, modified 'to a more positive form. " Under appropriate influences," says he, " insanity is among the most curable of grave diseases. If the persons who are attacked with this disorder are as promptly cared for as others when attacked with fever, dysentery, pneumonia, etc., eighty or ninety 'per cent, can be restored to health and usefulness."* But even this is the expression of a hypothesis which requires, as is shown above, an impossibility, — the placing of the patient under treatment as immedi- ately as in the other serious diseases mentioned. Familiarity with the writings of Dr. Jarvis, and a personal acquaintance with him of not less than thirty- five years, have led me to regard him as one of the * Fifth Annual Report of the State Board of Health of Massa- chusetts, page 382. THE CUKj^BILITY OF II^^SANITY. 45 ablest statistical pnilosopliers of the United States. Perhaps no American has been more deeply interested in the subject of insanity than he, and few have made themselves so extensively acquainted with its literature. His practical knowledge of it is, neverthe- less, but small. He has never been connected with a public hospital for the insane, except for a few years as trustee, and his experience in the treatment of the dis- ease is limited to cases in general practice, and a com- paratively very small number in a private asylum. Had his observation extended over the large numbers who have been under the care of any one of a dozen superintendents who might be named, he never, as I believe, would have written either of the foregoing ex- tracts ; for he is a conscientious searcher after truth, and no less conscientious in the expression of what he believes to be the truth. But the essence of the proposition is not original with Dr. Jarvis. Dr. Woodward, as has already been shown, expressed and published it forty years ago. Dr. Burrows did the same more than fifty- five years ago. Upon page 37 of the " Inquiry," already mentioned, he says he has " a clear conviction that it (insanity) admits of cure in a ratio equal with almost any disorder marked by as strong indications of morbid action in the corporeal system ;" and farther on (page 50), reasoning from his own success, as shown by his numerical statistics, he adds, " It is a legitimate inference that, if no other impediments than are usually opposed to the successful termination of cor- poreal diseases supervened, the recoveries of cases of insanity would be actually in excess" of those of other diseases. 46 THE CUKABILITY OF INSANITY. CHAPTER V. THE EBBING TIDE. It is now proposed to introduce the statistics of some authorities who have not found mental disorders, when treated within a twelvemonth from the time of invasion, to yield to curative measures in so large a proportion as most of those hitherto quoted. They deal with compara- tively large numbers of cases, and hence are more relia- ble as premises from which to deduce truthful results than the twenty-three cas^s of the Hartford Retreat, which, thanks to Basil Hall, made so much noise in the world ; or the thirteen cases of Dr. Gait, upon which he claimed the championship of success ; and, being based upon all the cases admitted, their results are more truth- ful, as an expression of actual curability, than the high- est percentages of Drs. Woodward and Awl, which were derived from the numbers of cases discharged. The first, and the most valuable for our present purpose, of these statistics, are those of the Friends' Asylum at Frankford, Philadelphia. They are the most valuable, because of the means of their analyzation, to a certain extent, with which I have been furnished by Dr. Worth- ington. The Friends' Asylum was opened in 1817. It is a small institution, the number of its patients at any time not having been one hundred. Hence every patient comes more directly and constantly under the observa- THE CURABILITY OF INSANITY. 47 tion and influence of the physician-in-chief, and is more subjected to individual treatment than is practicable in the large hosj)itals. No public or corporate institution in the country approaches more nearly to the ideal cot- tage plan. It has always been well managed, and its rank as a first-class curative institution has never, to my knowledge, been questioned. The report of that asylum for the year 1876 informs us that the whole number of cases of less than twelve months' duration, admitted since the opening of the in- stitution, was 1061. Of these cases, 697, or 65.69 per cent, recovered. This proportion is already small com- pared with some which have been noticed. But let us examine a little farther. Of these 1061 cases, 187 were of readmissions. Hence the number of persons was 874. Eighty-seven of \h.Q?,Q persons recovered 274 times, or 187 times more than the number (87) of persons. These were duplicate or multiplicate recoveries. Sub- tracting them (187) from the total (697) recoveries, the remainder is 510 recoveries, and these are the recoveries of personL Consequently, of 874 persons, 510 recov- ered. This is equivalent to a percentage of 58.35. This process makes a material alteration in the aspect of things, if the proposition be to ascertain the proportion of recoveries of insane persons. Only 58 (without the fraction) of each 100 recovered. 'And these were not all permanent recoveries. Of the 510 persons who re- covered at least once each, 87 were admitted on subse- quent attacks. Therefore, at most, only (510 less 87) 4!2?> persons were 'permanently cured. This is but 48.39 per cent, of the whole (874) , or less than forty-nine in each hundred. It is very far from certain, it is not even^ 48 THE CUEABILITY OF INSANITY. probable, that so many were permanently cured. Who knows how many of them suffered from subsequent in- vasions of the disorder, slighter, ^perhaps, than the first, and for this reason — or perhaps quite as severe as the first, and for some other reason, for such reasons are many — detained and treated at home ? Who can tell the number that, having a recurrence of the malady, were taken to some other institution ? Such changes are not infrequent, and in this instance would be particularly likely to occur, from the fact that, in the course of the period during which these persons were admitted, several other excellent institutions were established within the territory from which the Friends' Asylum, in its earlier years, received its patients. At some of the institutions, a number not inconsid- erable of the admissions of recent cases are not cases of insanity, properly so called, but of delirium tremens. My impression is that but few, if any, of these have been treated at the Friends' Asylum. But if any there have been, the number of them should be rejected, and the recoveries would thus be proportionately reduced. Any person who is interested in the subject will not neglect carefully to study the foregoing analysis. Con- sidering all the circumstances, there is no collection of eases in America which more fairly represent the actual curability of mental disorders when subjected to treat- ment within the year, than those of the Frankford Asylum. Yet, as they stand in mass, they offer neither ninety, nor eighty, nor seventy-five, nor seventy per cent, of recoveries ; and the moment their columns are broken and they are subjected to such analysis as will detect the number of persons recovered, the proportion THE CURABILITY OF INSANITY. 49 rapidly falls to a point below fifty per cent., still leaving unexamined influences which would probably carry it materially lower. The report for 1869 of the Asylum at Dayton, Ohio, which was at that time under the superintendence of Dr. Richard Gundry, contains the results of treatment, in respect to restoration, of all the patients admitted in the course of the fourteen years during which that in- stitution had been in operation. Of the 1427 cases the duration of which did not exceed one year, 831, or 58.23 per cent., recovered. But these were cases, not persons. Were the proper deductions made, as in the cases at Frankford, for readmissions, it would be found that the recoveries of persons was little, if any, in excess of fifty in the hundred. Other proper deductions would doubtless reduce them below fifty per cent. Of the 1427 cases, 530 came under treatment within one month subsequent to the attack. Of these, 363, or 68.49 per cent., recovered. The recoveries of 2jerso7is probably but slightly exceeded 60 per cent. The very large proportion taken thus early to the hosj^ital justi- fies the suspicion of many cases of delirium tremens, and many readmissions. Dr. Clodding, in the last published report of the State Hospital at Taunton, informs us that " out of 3131 patients admitted to the hospital,^ where the disease was of less than six months' duration at the time of admis- sion, 4-351 recovered." This is 43.14 per cent. These were cases, and not persons ; and they do not include the cases of from six to twelve months' duration, — the most incurable of the cases which have existed less than a year. In justice, however, to Dr. Godding, no less •50 THE CUKABILITY OF INSANITY. than to truth, both scientific and general, it should be mentioned that the pressure of patients upon the Taun- ton Hospital has been so great, for several years, that many have been hurried away from it without sufficient trial of curative treatment; and that doubtless there was a no inconsiderable number of those who would otherwise have recovered. It may here be mentioned, as bearing upon the sub- ject under discussion, that at the Worcester Hospital, under Dr. Woodward, during the second period of five years of its operations, the per cent, of recoveries of recent cases was 90.1, yet, twenty-four years later, under Dr. Bemis, during the period of five years, from 1864 to 1868, inclusive, it was but 68.8. In both instances these were cases, and not persons ; and the percentage was upon patients dischm^ged, and not upon patients admitted. Dr. Stearns, in the report of the Hartford Retreat for the official year ending with the close of March, 1876, asserts that during the first nine years of the operations of that institution, which was then in charge of Dr. Todd, 90.1 per cent, of recent cases recovered. Forty years afterwards, during the six years from 1869 to 1874, inclusive, under Doctors Butler, Denny, and Stearns, in succession, only 62.3 per cent, recovered. The proportion of recoveries during the first period was 44.62 per cent, greater than it was during the last period. If the proportion during the second period be represented by 100, that of the first period is represented by 144.62. The first European authority (Dr. Burrows) quoted in the discussion of this subject, is that of an eminent THE CURABILITY OF IIs^SANITY. 51 psychologist of London, fifty years ago. We have now arrived at a point where the recent language of another eminent psychologist, of the same city, may very appro- priately be introduced. He speaks not alone from his own observation, which has probably been as exten- sive as that of Dr. Burrows, but out of the accumu- lated knowledge of the vastly enlarged experience of the last half-century in England. Dr. G. Fielding Blandford, lecturer on Psychological Medicine at the School of St. George's Hospital, London, uses the fol- lowing language in his treatise upon mental disorders, lately published : " If we could carefully watch every case of insanity from its commencement, I fear we should see that a less number than fifty-three per cent, recover from the first attack, so great is the proportion of those who are in- curable from the first, or who, from the prejudices of friends, are not subjected to treatment till the chance of cure is gone; and if, by dint of- proper treatment, the above percentage recover, they only recover, again to become insane in a large proportion." Such was the testimony in the British capital, in 1870, precisely fifty years after the publication of the " Inquiry" by Dr. Burrows. •52 THE CUEABILITY OF INSANITY. CHAPTER VI. CURABILITY IN ALL HOSPITAL CASES. Having given a historical sketch of the means by which an impression of the eminent curability of in- sanity, in its recent stages, has been widely impressed upon the minds of persons more or less interested in the subject, and shown that the opinions of the writers who were chiefly instrumental in the production of that impression have not been sustained by subsequent and more enlarged experience, I now propose to give a cur- sory glance at the question of curability, in that broader signification which embraces all classes of cases, both recent and chronic, as they are received at the curative institutions. Every person who has made himself conversant with the operations of the hospitals during the last thirty years, cannot fail to have observed the constantly di- minishing number of reported recoveries, relatively to the number of patients admitted. At the State Hospital in Maine, in the five years from 1846 to 1850, inclusive, 587 patients were admitted, and 285, or a proportion of 48.55 per cent., recovered. At the same institution, in the five years from 1871 to 1875, inclusive, 953 were admitted, and 349, or a proportion of only 36.62 per cent., recovered. The difference in the per cent, of recoveries is 11.93. At the McLean Asylum, in the five years from 1823 THE CURABILITY OF INSANITY. 53 to 1827, inclusive, the admissions were 290, and the recoveries 118, or 40.69 per cent. ; while in the five years from 1871 to 1875, the admissions were 420 and the recoveries 91, which is only 21.66 per cent. The difference is 19.03 per cent. The proportion of recov- eries is but little more than one-half as great as it was half a century ago. At the Worcester Hospital, during the five years from 1839 to 1843, inclusive, 922 cases were admitted, and 448, or 48.59 per cent., recovered. During the five years from 1871 to 1875, inclusive, 2060 were ad- mitted, and 613, or only 29.75 per cent., recovered. The ratio of recoveries is but about three-fifths as great as it was thirty-five years ago. At the Utica Asylum, from 1848 to 1852, inclusive, 1890 cases were admitted, and 816 recovered, which is 43.17 per cent.; whereas, from 1871 to 1875, inclusive, 2125 were admitted, and 687, or only 32.33 per cent., recovered. The proportion of recoveries is about three- fourths as large as it was twenty-five years ago. In each of these illustrative instances, the beginning of the first of the two periods of five years between which a comj^arison is instituted was five years after the institution went into operation. For example, the Maine State Asylum was opened in 1840, and the first period used in the comparison is from 1845 to 1850. This was done for the j^urpose of avoiding the unnatu- ral or abnormal influence, whether favorable or unfavor- able, — ^as a general rule the latter, — of the cases which are taken to any new institution within the first year or more after its opening. After the lapse of five years, the current of admissions, it is assumed, has attained 54 THE CURABILITY OF INSAISriTY. its normal character in respect to the curability of the patients. In the last report of the Hartford Retreat, Dr. Stearns informs us that, at that institution, the percentage of recoveries " on all admissions" from 1824 to 1833, in- clusive, was 55.5. During the next^six years, from 1834 to 1839, inclusive, it was 56.90 ; during the five years from 1847 to 1851, it was 48.10 ; during the thir- teen years from 1855 to 1867, inclusive, 45.7 ; and during the six years ending with 1874, it was 37.8. The difference of the extremes is 19.1. Hence, in about forty years, the proportion of recoveries upon admissions diminished (from 56.9 to 37.8 per cent.) a little more than one- third. It is unnecessary to pursue this detailed illustration any farther. The cumulation of evidence may be pre- sented in a manner more condensed. The table here subjoined contains the princij)al facts of evidence, as furnished by the reports of twenty institutions. INSTITUTION. Second five years from opening. Last five years. Total admitted. Total recovered. Per cent, of second five years. Per cent. of last five years. Decrease of per cent. Augusta, Maine Concord, N. H Brattleboro', Vt " " McLean, Mass Worcester, Mass Taunton, Mass 1846-50 587 1 285 953 1 349 471 1 221 1 48.55 , I 36.62 46.92 : ! 32 97 11.93 13.95 is. 07 19.03 18.84 20.35 1871-75 1848-52 1872-76 746 793 667 290 420 922 246 *1841-46 1823-27 345 43.50 203 30.43 118 40 fi9 1 *1871-76 1871-75 91 448 613 492 21.66 48.59 1 29.75 4.^ 4fi ' 1839-43 1871-75 2060 1132 2189 1859-63 1871-75 506 1 9.^ n * These are periods of nix years each, rendered necessary by the fact that the hos- pitals issued reports biennially. THE CURABILITY OF INSANITY. 55 INSTITUTION. Second five years from opening. Last five years. ^S o > Butler Hospital U (1 Hartford Retreat " " .. Bloomingdale, N. Y 11 11 Utica, N. Y i( 11 Flatbush, n!' y!!.'." " " Trenton, N. J , 11 11 Pennsylvania Hosp. i°i 11 Dixmont, Pa .., 11 11 Catonsville, Md 11 11 Newburgh, Ohio.... II II Dayton, Ohio "ll u Indianapolis, Ind .. Jacksonville, 111 .... "n " .... Mendota, "Wis....;.. 1854-58 1829-33 1826-30 'i848-'52 1861-65 "1853-57 1846-56 is'ei-fii 1839-43 1860-64 1860-64 1853-57 *1855-60 1865-69 1872-76 *1876-7'4 '1871-75 1871-75 1871-75 1872-76 1871-75 '1871-75 1871-75 'l8'7i'-75 'l 870-74 'l8'7'i-76 *i869-7'4 187i'-7'5 279 520 324 533 635 602 1890 2125 1072 1700 715 996 1037 1371 479 1156 376 671 579 1352 492 1737 826 1932 937 1818 680 835 111 185 186 209 302 196 816 687 449 563 306 312 530 570 181 347 194 274 270 406 296 786 473 1014 436 581 230 216 39.78 57.'4b 47.55 43.'i7 ii'.'ss 42.79 51.10 37.78 51.59 46.63 60.16 57.'26 46.53 33.82 35.57 39.21 32.55 32.'33 33.11 3'l.'32 42.30 30. 6i 40.83 so.'os 45.25 52.48 3'l".96 25.86 4.21 18.19 15.00 ioM "8.77 11.47 8.80 7.77 io.'76 i6"."6b 14. '91 4.78 14.57 7.96 The total of admissions at the twenty institutions, in the course of the first period (second five years of operation), is 14,516; the number of recoveries, 6689; and the proportion of recoveries on admissions, 46.08 per cent. The admissions during the second period (last five years) were 24,383 ; the recoveries, 8354 ; and the per cent, of 4'ecoveries, 34.26. The recoveries diminished from 46.08 to 34.26, which is 11.82. The diminution of recoveries is equal to nearly twenty-six (25.65) per cent, of the recoveries of 56 THE CURABILITY OF INSANITY. the first period. For every hundred that recovered on an average of twenty-five years ago, only a fraction over seventy-four (74.35) now recover. The reader will observe that in all of the contents of this table, the figures relate to cases, and not to persons. The depreciation of percentage in such statistics, if the object be to ascertain the proportionate recoveries of insane persons, has been clearly illustrated. If only thirty-four (34.26) in each hundred of the eases now received into the hospitals are discharged recovered, the recoveries of persons cannot be more than about thirty in the hundred. CHAPTER VII. DEDUCTIONS. It has now been shown that, — 1. The reported recoveries from insanity are increased to an important extent by repeated recoveries from the periodical or recurrent form of the disease in the same ,person ; and consequently, — ^y 2. The recoveries of persons are much less numerous wtiian the recoveries of patients, or cases ; and conse- quently, — 3. From the number of reported recoveries of cases, or patients, it is generally impossible to ascertain the number of persons who recovered. 4. The number of reported recoveries is influenced, sometimes largely, by the temperament of the reporter ; THE CURABILITY OF INSANITY. 57 each man having his own standard, or criterion, of insanity. 5. The large proportion of recoveries formerly re- ported was often based upon the number of patients discharged, instead of the number admitted, and, gen- erally, upon the results in a number of cases too small to entitle the deduction therefrom of a general formula of scientific truth ; and those proportions were evidently increased by that zeal and rivalry which frequently characterize the earlier periods of a great philanthropic enterprise. 6. The assumed curability of insanity, as repre- sented by those proportions, has not only not been sus- tained, but has been practically disproved by subsequent and more extensive experience. 7. The reported proportion of recoveries of all cases received at the institutions for the insane has been con- stantly diminishing during a period of from twenty to fifty years. The last clause under the fifth of these heads sug- gests the remark that,3^t a later period in the life of Dr. Luther V. Bell than that in which he wrote what is quoted in this article, his opinions in regard to the general curability of mental disorders underwent an important modification. He then regarded them as far less susceptible of cure than he had believed them to be in his earlier years ; and the language which he used upon the subject contrasted so strongly with some of that which is herein quoted from his writings, that it might be alleged as indubitable proof that " a wise man sometimes changes his opinions." If the causes of the general reduction of the projDor- 5 58 THE CURABILITY OF INSANITY. tion of recoveries, as stated under the seventh head, be sought, some of them will be found in, or inferred from, preceding portions of this discussion. Among others are, first, the probable fact that, as in- stitutions have multiplied, the proportion of chronic and incurable cases taken to them has increased; and, secondly, the not improbable fact that insanity, as a whole, is really becoming more and more an incurable disease. If it be true, as asserted by that accomplished scholar and profound thinker, Baron Von Feuchtersle- ben, — and doubtless no one will deny its truth, — that in the progress of the last few centuries, as civilization has advanced and the habits of the race have been con- sequently modified, disease has left its stronghold in the blood and the muscular tissues, and at length seated itself in the nervous system ; it follows, perhajDS, as a necessary consequence, that by a continuation of the cause of this change, the diseases of the brain and nerves must become more and more permanent. Hence it has happened that the proportion of recov- eries from insanity has not kept pace with the improve- ment of hospitals and of the management of the insane. Dr. Isaac Ray, in his report of the State Hospital in Maine, for the year 1 844, asserted that " he would be a bold man who should venture to say that Pinel and Esquirol, whose medical treatment was confined chiefly to baths and simple bitter drinks, were less successful in their cure of mental diseases than those numerous practitioners who have exhausted upon them all the resources of the healing art." If the assertion was true thirty-two years ago, it is believed that the contents of this exposition sufficiently THE CURABILITY OF IIS'SANITY. 59 prove that it is, to say tlie least, none the less true at the present day. The years of a generation have passed since that time, and, in the course of their j)ro- gress, remedy after remedy before untried has come u]), big with the word of promise to the hope, but essen- tiallyl3reaking it to experience. Haschish was experi- mentally tried, ]d roved a failure, and is now nearly forgotten. Chloroform and ether have become conven- ient and useful to a certain extent, but they have no curative power previously unknown in other remedies. The same may be said of chloral and the bromides. Electro-magnetism, upon which great hopes were placed, is vei^ beneficial in a few cases of disordered nervous action, but hitherto has proved itself powerless to cor- rect those cerebral functions the abnormal operations of which constitute insanity. It would appear, indeed, that the truth of Dr. E-ay's proposition would have been little if any affected, if he had gone back to a period a full century anterior to the time of Pinel. Dr. Burrows informs us, on the author- ity of Dr. Tyson, physician at Bethlehem at the time, that from 1684 to 1703, 1294 patients were admitted to that hospital, and 890 recovered. This proportion of recoveries is almost sixty-nine (68.77) in the hundred. But epileptics, paralytics, and perhaps some other incur- ables, were not admitted at Bethlehem at that time. The reported recoveries at the same hospital, one hundred years later, in the decade from 1784 to 1794, were thirty-four in a hundred. By a remarkable coin- cidence, this proportion is almost identical with that (thirty-four and one one-hundredth) of the recoveries in all the institutions for the insane in England and Wales 60 THE CURABILITY OF INSAXITY. during the sixteen years from 1859 to 1874, both inclu- sive. In approaching a conclusion, I quote from Dr. Thur- nam his estimate of the curability of the insane, derived from a more thorough investigation of the subject, as presented in the patients treated at the Retreat in York, England, during a period of forty-four years, than has ever been attempted by any other writer. I have long regarded this estimate as the most nearly accurate, and hence the most reliable, of any that has been published ; and it is believed that the attentive reader of what has here been written will have arrived at a similar conclu- sion : " In round numbers, then, of ten persons attacked by insanity, five recover, and five die, sooner or later, durino- the attack. Of the five who recover, not more than two remain well during the rest of their lives; the other three sustain subsequent attacks, during which at least two of them die. But, although the picture is .thus an unfavorable one, it is very far from justifying jthe popular prejudice that insanity is virtually an in- curable disease ; and the view which it presents is much modified by the long intervals which often occur between the attacks ; during which intervals of mental health '(in many cases of from ten to twenty years' duration) ^- the individual has lived in all the enjoyments of social ff^''' Drs. Bucknill and Tuke, in their "Psychological Medicine," by far the best general treatise upon insan- ity in the English language, — and there is reason to believe that it has no superior in any other language, — so far endorse the results obtained by Dr. Thurnam, as I THE CUEABILITY OF INSANITY. 61 to quote, not alone this extract, in which they are em- bodied, but the statistical table from which they are derived. CHAPTER VIIL CONCLUSION. OuK attention may now be redirected to the propo- sitions at the beginning of this discussion, with a view to ascertain the effect of the facts and opinions herein adduced. In brief, then, it appears that it may fairly be asserted, first, that all estimates based upon the assumption that either seventy-five, or seventy, or sixty, or even fifty per cent, of the persons attacked with insanity can, at the time of admission to the hospi- tals, be cured and returned to the class of permanent producers in the sphere of human labor, are necessarily false, and consequently are both " a delusion and a snare;" and, secondly, that if the Vermont Asylum for the Insane- can be justly censured or condemned because of the diminution in the proportionate number of its reported recoveries, its sister institutions, through- out the land, are generally in the same category of censurable organizations, and are open to__a_like con- demiiatinn^^ Although it has here been shown, beyond cavil or question, that, as a whole, the cases of insanity are less curable than has, by many, heretofore been believed, and that the same is far more emphatically true of insane persons ; yet, by so doing, no argument has been 62 THE CUEABILITY OF INSANITY. developed against the utility of hospitals, nor has the practical value of those establishments been in the least diminished. False impressions of their value may have been corrected ; and, to that extent, not alone has the cause of truth, which is better than error, been pro- moted, but a measure of protection has been furnished to the medical officers of the hospitals. The declara- tions of the earlier superintendents are returning, like boomerangs, to spend their ultimate force upon their promulgators, or, as in the instance of the Vermont Asy- lum, herein mentioned, upon the persons now standing in the places of their promulgators. It is here dem- onstrated that there is a proper shield against their offensive assaults. Meanwhile the institutions for the custody and cure of the insane have become a public necessity, and have proved themselves a greatly beneficent blessing to the people. Through their ministrations very many per- sons of disordered or perverted intellect have been restored to their homes, their friends, and their spheres of usefulness in society, permanently " clothed and in their right mind." Even to the political economist, or the sheerest utilitarian, this is a fact of significant im- portance ; and, by the philosopher, the philanthropist, or the Christian, it must be regarded as a blessing above and beyond all estimate in standards of pecuniary value. Nor are the duplicate or the multiplicate recov- eries of the persons subject to mental disorders of the recurrent type, to be too lightly estimated. A recovery is none the less desirable, and none the less valuable to the person, or to society, so long as the person remains {/well, because it is of limited duration. THE CURABILITY OF INSANITY. 63 While, then, the hospitals continue their progress in the fulfilment of their beneficent mission, it would ap- pear that the better course for the superintendents is to discard, universally, as they already have discarded, to a great extent, the classification of their cases according to duration ; but constantly to keep before the people the great truth that, as a rule having comparatively few exceptions, the sooner the person attacked with in- sanity is placed under curative treatment, the greater is the prospect of recovery. STUDY SKCOND. (WRITTEN IN 1877.) The First Study contains an exposition of the means by whicli, prior to 1876, it had become a commonly received opinion, among non-professional persons in- terested in the subject, in this country, that insanity is an eminently curable disease. It is there shown that, by mistaking cases for persons, and percentage of recov- eries of patients discharged for percentage of recoveries upon patients received at the hospitals, it had come to be generally believed, that, if sufficiently early subjected to treatment, from 75 to 90 per cent, of all persons becoming insane can be cured, and restored from the class of mere consumers to the class of producers of the necessities for human sustenance. " A wise man," says Pinel, " is cautious how he be- comes the echo of a commonly received opinion ;" and the necessity and prudence of such caution are strik- ingly exhibited in the results of our exposition of methods of reporting, and in our analysis of some of the most trustworthy statistics upon which the aforesaid opinion must rely for its support. That opinion has been not only echoed, but re-echoed, throughout the land. A comparatively brief discussion of its merits has demonstrated it to be one of the greatest of fallacies. 64 THE CURABILITY OF IISrSANITY. 65 It is there shown that a very important proportion of the recoveries of recent cases are merely the tem- porary and repeated restorations of a comparatively small number of persons from paroxysms, more or less transient, of periodical or recurrent insanity. As, in a theatre, a score of supernumeraries, marching in regi- mentals across the stage and disappearing only to reap- pear again, may impress the uninitiated with an ideal army of no insignificant numbers ; so, in the drama of life, a few men and women, by entering and leaving the hosj)itals, as they sometimes do, with an industry of change quite remarkable, may send forth to an ad- miring world a large number of statistical recoveries. And as, upon the stage, the few men who appear as an army of soldiers are not soldiers ; so most of the small number of persons who, at the hospitals, make a show of many recoveries, have not really recovered. In the former case there are no soldiers; in the latter, no — or but few — -permanent cures. The almanac, a very popu- lar work on statistics, reports thirteen new moons every year ; and yet all of these new moons are nothing more nor less than the old one. So Worcester Hospital had a patient who recovered seven times, and hence was counted as seven patients recovered, in one year ; and yet she was nothing more nor less than the old patient who had recovered five times in the next preceding year, and four times in the year one farther removed in the past. " How many cows have you ?" inquired a man of an amateur farmer. " My brother and I," was the reply, "have twenty." Now, although this statistician told the truth, so far as he spoke, and although "figures 66 THE CURABILITY OF INSANITY. cannot lie," yet it so happened tliat the inquiring man was grossly deceived. The whole truth in regard to possession was, that the brother owned nineteen of the cows, and the man himself only one. The superintendents may honestly claim that they truthfully report their recoveries ; but, nevertheless, they report them in such manner that they have been greatly misunderstood, and have consequently led to the most glaring errors. The courts of judicature re- quire a pledge to tell not only the truth, but the whole truth. New Hampshiee Report. — It is very easy, in j^re- paring their reports, for the superintendents of the hospitals so to explain their cases of recovery that the general misapprehension in regard to them may be cor- rected. Dr. Bancroft, of the State Asylum at Concord, New Hampshire, in his last rejDort, which was written since the publication of the First Study, has introduced such an explanation. His recoveries, as reported iai mass, were thirty-six ; but, in allusion to them, he says, ^^Fifty-eight per cent, of the recovei^ies are of persons who have some time recovered from previous attachs.^""^ Furthermore, he publishes a new table, in which he shows the number of attacks from which they had re- covered. The exposition is, in brief, as follows : Of the thirty-six persons who recovered, twenty-one (58 per cent.) had previously been insane and recovered. Eight had previously recovered from one attack ; seven from two attacks ; one from three attacks ; two from four at- tacks ; one from five attacks ; and two from seven attacks * Not italicized in the orio;inal. THE CURABILITY OF INSANITY. 67 each. In other words, those twenty- one persons had pre- viously given fifty-two recoveries to the statistics of the hospital. They have now given twenty-one more. Their total of recoveries is, therefore, seventy -three, or nearly four to each person ; and they have gone out of the in- stitution, unquestionably not " permanently restored to the class of producers," but most, if not all of them, to return again, and some of them many times, each re- cording an additional recovery at every time, and thus swelling that crowd of hypothetical or assumed persons recovered, upon which rest some of the calculations of deluded statisticians. Most decidedly the doctor's explanation throws abun- dant light upon what otherwise, having the aspect of light, would really have been delusive darkness. In the interest of truth it is to be hoped that others will foUow his example. And wherever it may be followed, similar results will most certainly be reached, — results alike in character, but differing in degree according to the age, and, to some extent, the situation of the hospital. As a rule, and to the extent of a considerable series of years, the older the hospital, and perhaps the nearer its situation to a large city, the greater will be the number of double, triple, and multiple recoveries of individuals. Delieium Tremens in Insane Hospitals. — It is asserted in the First Study, that " at some of the insti- tutions a number not inconsiderable of recent cases are not cases of insanity proper, but of delirium tremens ;" but no attempt was made to illustrate the proposition by any positive statistical information. The assertion might have had the still stronger extension, that a number not inconsiderable of the recent cases which flourish as re- 68 THE CURABILITY OF II^SAJ^ITY. coveries in American statistics were cases of sheer and simple drunkenness, without any delirium whatsoever. It is possible that these assertions are more emphatically a23plicable to the cases at the Bloomingdale Asylum, New York, than to those of any other hospital in the country. Yet there are good reasons for the belief that there are several other institutions the records of which contain large numbers of such cases ; and that a liberal sprinkling of them may be found in nearly all. Nearly thirty years ago I published an analysis of the cases treated at Bloomingdale, from the time of its opening to the close of 1844, a period of twenty-three and a half years. The number of admissions was 2937. In the classification of these cases, no less than 594, or a trifle more than one-fifth of them, were placed under the head of delirium tremens, including the cases of mere habitual drunkenness. It is possible, also, that there were a few whose mental disorder was a little more prolonged than that of delirium tremens, and hence might have been more appropriately classed as the mania of alcoholism. But the number, if any, was small. These 594 cases were furnished by 322 persons, many of whom were admitted more than once. These 322 persons (making, by re-admissions, 594 cases) furnished 512 recoveries to the statistics of the institution. Thus, in the medical records of the Bloomingdale Asylum, prior to the year 1845, there are 512 recoveries from delirium tremens and ordinary fits of drunkenness, loliich still stand in their tables of statistics, as published in their annual reports to the present timie, as recoveries from insanity ; and whosoever uses the statistics of that THE CUKABILITY OF HS^SAISTITY. 69 asylum, as they are published in those reports, to illus- trate any question relating to insanity, uses those 512 recoveries from delirium tremens and ordinary inebriety. Dr. Gray, of the State Asylum at Utica, has for some years reported such cases, not as recovered, but as " not insane." Dr. A. E. Macdonald, of the New York City Asylum, Ward's Island, reports them in the same way. In his report for 1876, he alludes to those who left the asylum within the year in the following language : " The fifteen discharged as ' not insane' would, in the reports of some asylums, be classified as cases of ' dipsomania,' or ' alco- holic mania,' and used to swell the total of recoveries. I do not so use them, because they were simply drunkards, suffering from the effects of a debauch ; and I do not consider them entitled to have the mantle of insanity, and therefore of irresponsibility, thrown over their misdeeds." Dr. Macdonald evidently believes that drunkenness is a vice, and not a disease. Peoportionate Decrease of Kecent Cases. — Notwithstanding the fact that the advantages of early treatment have been constantly proclaimed in the annual reports of the hospitals, for nearly half a century, there is, to-day, no reason to believe that any larger proportion of the insane of Massachusetts are taken to the hospitals in the acute stages of the disorder than in the earliest years of the history of the hospital at Worcester. Of all the admissions to the public institutions, the proportion of recent cases appears indeed to be smaller now than it was at that remote period. This result, however, is apparently to be accounted for by the supposition, not 70 THE CTJKABILITY OF INSANITY. that fewer recent cases, but that a larger number of old cases, are removed to those institutions. As hospital accommodations have increased, more and more of the large class of the chronic insane, who formerly remained among the people, are thus removed from their homes. This non-increase of recent cases in the hospitals has in some places been attributed to an increase of pre- vailing prejudices against those institutions. I cannot regard this hypothesis otherwise than as erroneous. Those prejudices were, in my estimation, as general and as strong forty years ago as now. No hospital in Massachusetts has been more subjected to unjust censure among the people than that at Worcester, when under the care of Dr. Woodward; and no superin- tendent has had harder stories, or, probably, more that were untrue, told of him, in what Dr. Bell, writing upon the subject, in reference to the McLean Asylum, called the " undertow of society." If prejudices against the institutions have had so potent an effect, and if those prejudices have been increasing, how happens it that, in Massachusetts, although hospital after hospital, in pretty rapid suc- cession, has been erected, yet, as each one was opened, it was soon filled to overflowing, and a little later be- came crowded, almost packed, with inmates, as the three large State hospitals have been during the last two or three years ? English Asylums. — Dr. Bucknill would have us believe, and some of our American writers appear to believe, that those prejudices — prejudices suffered in common by all institutions for the insane, the world over — have mostly been overcome in England, through THE CURABILITY OF INSANITY. 71 the beneficent surveillance of tlie commissioners in lunacy. Be that true, or be it not true, there certainly has been no great rush of recent cases into the hosj^itals in that country, as a consequence of this asserted im- provement in the public estimation of them. On the contrary, we find the same process of increase of chronic cases admitted, going on in the institutions of our father- land as in our own. In his report for 1876 of the Derbyshire Lunatic Asylum, Dr. J. Murray Lindsay uses the following language : " The admissions of the past year have been of a still more unfavorable class than usual, both as regards their physical condition, mental state, and duration of insanity. . . . Instead of the asylum being looked upon as a hospital, to which patients laboring under mental aberration should be sent in the earliest stages of their malady, there appears to be an increasing tendency to detain them at home, and to delay sending them to the asylum until every resource has failed, and then to -the asylum as the last refuge." Dr. Samuel Mitchell, superintendent of the South Yorkshire Asylum, informs us, in his report for 1874, that of 363 patients admitted within the year, " only a small number were brought suffering from insanity in its earlier stages ; on the contrary, they arrived here showing all the symptoms of the disease in its most advanced and incurable forms." . ..." So earnest," says he, " in many cases, is the endeavor on the part of their friends to keep at their homes patients suffering from mental diseases, that it is quite the exception ever to receive into the asylum a patient in the early stages of general paralysis, — a form of mental alienation in 72 THE CURABILITY OF INSANITY. which the sufferer usually becomes so troublesome as to require constant supervision in its earlier manifesta- tions." The condition of things is much the same in Wilt- shire. Dr. J. Wilkie Burman, in his report for 1873, says, " I regret to have to state that the admissions con- tinue to be of a very unfavorable nature, as to prognosis and prospect of recovery, in a large proportion of the cases." And in his report for 1875 it is asserted that " in only fifty-five out of the one hundred and thirty cases admitted during the year, was there the slightest reason to entertain hopes of recovery ; and, of these, twenty-three have been discharged recovered, four have died, and the rest remain, in only a few of whose cases is any improvement expected." Dr. James Sherlock, of the Worcester Asylum, testi- fies strongly in the same direction, in his report for 1874. " The cases received," says he, " have for several years past been of an eminently unfavorable class. It is remarkable how few cases of recent acute mania and melancholia are passed to our care from year to year ; but the number of those who gradually subside into an irresponsible, unmanageable, and insane state continues unabated." ..." It is probable that now, at the end of the twenty-second year of the existence of your asy- lum, there are not received, from year to year, more recent acute cases than were consigned to it in the earlier years of its establishment; but the number of patients whose insanity has been gradually developed from defect of diagnosis, and by the lapse of proper preventive means, has largely increased. Many such of the latter class are now regularly sent here, but not THE CURABILITY OF INSAISITY. 73 at a date sufficiently early to insure recovery, or even improvement." Dr. T. Algernon Chapman, of the Hereford Asylum, in an interesting article in the Journal of Mental Science for July, 1877, says, " It remains a great fact that a mass of incurable cases are being forced into our county asylums." He maintains, however, that a very large proportion of them were never curable ; that they are " cases of gradually progressive insanity," or of *' in- surable brain-disease," or of senile insanity, idiocy, and epilepsy. From Wales, which is within the jurisdiction of the English Commission in Lunacy, we have the testimony of Dr. G. J. Hearder, who, in the report for 1874 of the Carmarthen Asylum, wrote as follows : " It is a most lamentable fact, that for every case sent here for treatment, while treatment will avail, three cases are allowed to sink, by continued neglect, into a state of utter hopelessness." If, then, in England, where so many institutions have existed for so long a time ; where the population is almost stationary, in regard to residence, as compared with the migratory people of this country; where all branches of the civil service of the national, the county, and the municipal governments are, and long have been, so perfectly organized and so efficient in administra- tion, and where a commission in lunacy has exercised ia watchful supervision during a period of more than thirty years, — if, under these circumstances, it has there been impossible to increase the proportion of curables received at the hospitals, to induce the relatives or guardians of those who become insane to take them in 6 74 THE CURABILITY OF INSANITY. the early stages of the disease to the curative institu- tions, and to prevent, by curing these recent cases, the increase of the number of the insane, how can it be expected that those objects should have been accom- plished in this country ? Supposed Causes of Delay. — It has long appeared to me that he who seeks the true causes of delay in the removal of the insane to the institutions provided for them, must look to social life, to the homes and the rela- tives of the persons who are proper subjects for the ministrations of those institutions ; and I have recently met, in a foreign report, views so nearly coincident with my own, that I here reproduce them. " The recourse to asylum treatment," says Dr. James C. Howden, in his report for 1875 of the Montrose Asylum, Scotland, " may be assumed in every case to be a matter of social convenience. In recent cases, of course, the probability of recovery to a certain extent influences relatives; but in far the greater number of instances the exigencies of the situation settle the point, and the patient is sent to the asylum because he cannot be conveniently kept at home." But what are the motives for such delay ? They are various : motives of afiection, motives of economy, and not infrequently motives of pride. Hence, how much soever institutions may be improved, or to what extent soever prevailing prejudices in regard to them may be overcome,- — and I have little faith that there will be much change in that respect, — it is very doubtful that the insane, as a whole, will ever be placed under hos- pital treatment at a much earlier period of their disease than they are at the present time. THE CURABILITY OF INSANITY. 75 Dr. Mitchell's Essay. — The Journal of Mental Science^ in its issue for January, 1877, contains an arti- cle by Dr. Arthur Mitchell, one of the Commissioners in Lunacy for Scotland, which is the most valuable original statistical contribution to our knowledge of the actual curability of insanity, as first recognized at public institutions, that has appeared in many years. As Com- missioner in Lunacy, Dr. Mitchell has at hand all the statistics of all the institutions for the insane in Scotland. Hence, if a patient is discharged from one asylum, and, either immediately or at some subsequent period, is re- ceived into another, he is informed of it. In this way every patient admitted to any asylum may be afterwards followed, so long as he remains in any public institution in the country, no matter how frequent the changes may be. The object of Dr. Mitchell's article was this : to take all the persons admitted for the first time into all the Scottish asylums, in a given year, and, twelve years afterwards-, to show what had become of them, and what was their mental condition, if living, or, if dead, at the time of death. The most important of the statistics of the article are as follows : The number of patients (in this instance, persons) admitted in the year 1858, was 1297. Twelve years afterward, in 1870, it was found that 412 of them had already died in the asylums, and 273 remained in them. Thus 685, insane at death, or still insane, are accounted for. The remaining 612 had disappeared ; but the history of 411 of them was successfully traced. 76 THE CURABILITY OF INSAmTY. 42 of them had died insane. 94 were living, and insane. Total, 136 insane. 78 had died not insane. 197 were living, and not insane. Total, 275 not insane. Hence, of 1096 persons whose history was traced, 454 had died insane, and 367 still lived, insane. Total, 821 insane. And 78 had died not insane, and 197 still lived, not insane. Total, 275, not insane. Percentage of insane, 74.91 — ; percentage not insane, 25.09+. In general terms, three-fourths were insane, and one-fourth not insane. On the assumption that, of the 612 who had disap- peared from the asylums, the results of the 411 whose history was traced were equally true of the 201 whose history had not been traced. Dr. Mitchell, in a foot-note, gives the general results in regard to the whole of the 1297 persons. In proportions these results are as fol- lows: Dead, insane at the time of death . . 36.6 per cent. Alive and insane . . . . . 31.7 " " Alive and sane, or sane at death . .31.7 " " Good as Dr. Mitchell's paper is, let it not be forgotten that it does not give final results, except in the cases of the dead. Of the 197 persons known to be still living and not insane, and the 97 who, of the untraced 201, are THE CURABILITY OF INSANITY. 77 assumed to be living and not insane, it is very likely that a not unimportant number will yet return to the asy- lums, and die there. Making due allowance for these, it is quite apparent that the final results, in regard to these 1297 persons, will approximate closely to the final results in the cases of 244 persons, as shown in the best and most reliable of all essays ujDon the subject in the English language, — best and most reliable simply and only because its results are final. The essay alluded to is that of which the general statistics are given below. De. Thuenam's Investigation. — Dr. Thurnam traced the history, until death, of 244 persons treated at the Friends' Ketreat, near York, England, and obtained these results : Died insane during first attack Recovered from first attack . Kecovery permanent (of the 131), died sane Had subsequent attack .... Died insane (of the 86) Recovered, and died sane 113 131 244 45 86 — 131 66 20 — 86 Generalizing from these data, he formulated the rule* of curability quoted in Study First, page 60. * In the fourth edition of their treatise on Psychological Medi- cine, page 131, Drs. Bucknill and Tuke say, in regard to the rule referred to, " It would be more strictly correct to say, of eleven persons attacked by insanity, six recover, and five die sooner or later during the attack. Of the six v^ho recover, not 78 THE CURABILITY OF INSANITY. All of the original statistics of all the American insti- tutions for the insane, wherever, whenever, and in what manner or form soever published, are of less value in determining the question of the curability of the insane, at the time when they first enter the hospitals, than the two papers of Dr. Mitchell and Dr. Thurnam. The conclusions of the latter, although before the profession for a generation, have very rarely been quoted ; but, in their stead, the public have been almost constantly en- tertained by the now essentially traditional assertion, " from eighty to ninety per cent." (or something like it) " can be cured," — assertions which, in the language of Dr. Bates, published almost thirty years ago, "are received with wondrous admiration by that portion of the public who are better pleased with marvellous fiction than with homely truth." " To this complexion have we come at last ;" and nei- ther physicians, nor humanitarians, nor political econo- mists, nor other scientists, need longer lay the flattering unction to their souls, that even forty, and much less fifty, sixty, seventy, or seventy-five per cent, of insane persons, as they first appear at the hospitals, can be per- manently cured and restored to the class of producers. They will be obliged to look the problem of insanity and the insane fairly and squarely in the face, in the aspect under which it is here represented; for though they build, as a hospital for the insane, a temple costly as that of Solomon, or a tower like that of the plain of more than two remain well during the rest of their lives ; the other four sustain subsequent attacks, during which at least three of them die." THE CURABILTTY OF INSANITY. 79 Shinar, upon the highest hilltop of every county in the land, they will not essentially alter it. There is a time for everything. That the time had fully come in which a new review, in this country, of the subject of the curability of mental disorders was specially important, there are many evidences. Not the least of these was the situation of general statisti- cians, who, impressed with the belief that " from sev- enty-five to ninety j)er cent." of the insane are suscep- tible of cure, were floundering in the dark, and vainly endeavoring to explain the rapid increase of the number of those mental invalids among the people. In this, and in other connate questions, a vast amount of time, labor, pens, ink, and paper has been wasted by authors and printers : worse than wasted, because the deduc- tions, conclusions, or supposed demonstrations, so far from being the essence of truth, were oftentimes among the most egregious of errors. Among the many persons who have expressed their satisfaction with the First Study is Dr. Nathan Allen, of Lowell, whose statistical and other works, upon various important subjects, have deservedly given him a Euro- pean, as well as an American, reputation. " Please accept," he writes, " my thanks for your valuable paper upon the Curability of Insanity. To what extent this disease can be or is actually cured, there has been a wide difference of opinion, as you well know, even among expert writers on the subject. Your facts, statistics, and conclusions must go far to settle this question, that the percentage of cures has been rated altogether too high. ^^ Had your paper been placed in my hands many 80 THE CUEABILITY OF INSANITY. years ago, it would have saved me much labor and trouhle^ It is a consolation to believe that many other writers could truthfully make the same acknowledgment as that expressed in Dr. Allen's closing paragraph. " I have just read your report," writes an active mem- ber of the board of charities of a distant State, " and can- not refrain from writing a few lines to express my great satisfaction with your most valuable discussion of the curability of insanity." An eminent physician, a professor in a medical school in another and remote State, says, " Your chapter on the curability of insanity is most instructive and full of in- terest. If the misstatements of general practice could be illumined by the same light which you have thrown upon your special labor, there would be more ground for hope of a useful and honorable future for medicine." Another physician, well known for his interest and his labors in the broad field of science which includes the great questions of public welfare, writes as follows : " Your statement of the curability of insanity, and your analysis of the reported cures of insanity in asy- lums, is, in my opinion, a valuable public service. When the public learn that asylum superintendents desire to state the truth, and not merely to commu- nicate what information they — the superintendents — think it is best for the public to know, popular distrust of asylums will cease." Let not the reader too hastily infer, from the last sen- tence of this extract, that there is a conspiracy among the superintendents, the object of which is to mislead public opinion in regard to the subject under discussion. THE CUKABILITY OF INSANITY. 81 Letters of approval have reached me from a no inconsid- erable number of those superintendents. One of them, who is well and widely known as the successful chief officer of one of the largest State institutions, thus expresses his views : " I write to satisfy an impulse that has had possession of me for some time; and that is, to say how much gratified I was with your last report, and your article on the curability of insanity. You are undoubtedly right in the views expressed as to the unreliability of the cures reported by almost all the hospitals. If all the statistics were sifted as thoroughly as you have sifted a few of them, I am afraid the percentage of cures would prove exceedingly small." Another, who has likewise long presided over a large State hospital, writes as follows : " Accept my thanks for your argument and conclusions in relation to the cura- bility of insanity. I had arrived at the same figures, but have been not a little embarrassed by the statistics of others. The matter is clear now." " It has been a wonder to me," writes a third, equally well known as the efficient head of still another among the largest State institutions, " that members of the pro- fession have not spoken as plainly before now, as you have done." It might not inappropriately be asked, Why has he not done it himself? He is abundantly able to grapple with the subject, but his memory does not reach so far into the past as that of some other persons ; and perad- venture his facilities for reference to the earlier reports are less extensive. " I am very much pleased with your report," writes 82 THE CURABILITY OF INSANITY. an ex-superintendent of yet another of the large State hospitals. " Your exposure of some practices and falla- cies was eminently proper." No one of the institutions above mentioned is in New England ; and no two of them are in the same State. No person, indeed, who has been quoted, with the single exception of Dr. Allen, resides easterly from the Hudson River, and some of them are far west of it. In regard to the superintendents of hospitals in the six Eastern States, it is sufficient to say that the paper was read at a meeting of the New England Psychological Society, when six of them — five beside the writer — were present, and that, by a unanimous vote, they directed that it be printed. STUDY THIRD. (WRITTEN IN 1878.) With a knowledge of the contents of the foregoing Studies, it may well be considered a matter of surprise that some method has not been adopted at the hospitals of so reporting recoveries that the reader may clearly understand how many of them are from first attacks and how many from attacks subsequent to the first. I con- sider this remark as more applicable to the British hospitals than to those of the United States, both because, as a whole, they are the older, and because the science of statistics has been brought to a greater per- fection in that country than in this. Nearly all of those foreign hospitals very carefully discriminate, in their tables of admissions, between first admissions and re- admissions. Wherefore are they not equally careful, in their tables of recoveries, to discriminate between first recoveries and re-recoveries ? The utility of their sta- tistics would be quite as much increased by the latter course as by the former. In England and Wales, from 1859 to 1874 inclusive, the stated recoveries in all hos- pitals and asylums for the insane were 34.01 per cent, of the admissions. This result, as showing the cura- bility of eases, or attaehs, has its value ; but, when the relation of insanity to all other subjects of human 83 84 THE CURABILITY OF INSANITY. interest is taken into consideration, would it not have been more valuable to know what jDercentage of the persons recovered ? I turn, however, from this subject to the consideration of the question, Are recoveries from insanity in a direct ratio to the cost of treatment ? The proposition involved in this interrogation would not be devoid of interest at any time ; but at this juncture, after the experience of the last few years in greatly increasing the cost of hospitals, under a vague impression that recoveries from insanity will always be in direct ratio to the sum of pecuniary expense bestowed upon the patients, it be- comes a matter of absolute importance. That degree of bodily comfort which is necessarily included in the best attainable hygienic conditions — pure air, cleanliness of person and surroundings, suffi- cient wholesome and nutritious food, a proper amount of exercise, and protection from the inclemencies of the weather — is doubtless essential to the attainment of the greatest probability of cure; but it is quite doubtful that, beyond this attainment, the lavishing of money, however profusely, in mere luxuries, is of any benefit. And yet there are many persons who appear to think that it i^, and who measure their hope of recovery by the sum of money expended. To such an extent, indeed, is this notion sometimes carried in practice, that the very object of treatment is apparently thereby defeated, and recovery is prevented instead of secured. There are no statistics by which either the affirmative or the negative of our proposition can be positively demonstrated ; but there are some which offer an inter- esting study when considered in relation to it, and, so THE CUE ABILITY OF INSANITY. 85 far as they go, would seem to prove tliat increase of expenditure does not enlarge the proportion of cures. I allude particularly to the statistics of the McLean Asy- lum at Somerville, Massachusetts, one of the oldest cor- porate institutions for the insane in the United States. In 1840 that asylum was under the medical care of Dr. Luther V. Bell. In the course of that year one hun- dred and fifty-five patients were admitted, and the reported recoveries were seventy-five, which is equal to 48.38 per cent, of the admissions. The average weekly cost of su23port of the patients was, for that year, three dollars and fourteen cents each : in other words, when paying three dollars and fourteen cents each per week, forty-eight patients in the hundred recovered. Thenceforward, although with some fluctuation from year to year, there was, upon the whole, a gradual increase in the current expenses of the institution, until, in 1875, the average weekly cost for each patient was twenty-one dollars and seven cents. The increase of cost during the period of thirty-five years was 671 per cent., or a small fraction less than sevenfold. In the course of that period, the Appleton Wards, which for luxurious accommodation will not suffer by comparison with the best in Europe, were erected, as well as the two buildings for refractory patients, which, so far as I am informed, are unequalled in elegance by any others for that class in the world. With these additional elegancies of accommodation, and a nearly sevenfold augmentation of current ex- pense, what was the condition of things in regard to recoveries ? Were they increased, not, indeed, seven, nor six, nor five, nor even three fold, for that would 86 THE CURABILITY OF INSANITY. have been impossible; but were they doubled? Alas, no ! They had diminished sixty-one per cent, of the ratio in 1840 ; so that, instead of forty-eight (48.38) recoveries to the hundred admissions, there were only nineteen (18.82). The number of patients admitted in 1875, the closing year of the period, was eighty-five, and the number of recoveries sixteen, equal to 18.82 per cent. The following table has been prepared in justifica- tion of the foregoing assertions. Beginning with the year 1840, it was intended to present the results of every fifth year subsequently, until 1875. The reports, however, of several of those years were not readily accessible, and consequently the available years most nearly approaching those fifth years were taken. The years 1876 and 1877 were added to show that the diminished proportion of recoveries was not a temporary incident. 1840 1846 1848 1854 1855 1859 1861 1865 1870 1872 1875 1876 1877 Admit- Recov- Daily ted. ered. Average 155 75 128 148 65 164 143 82 171 120 59 195 123 56 192 131 61 185 111 54 193 82 38 186 79 33 187 93 15 173 85 16 151 92 18 160 110 15 175 Whole Cost. $20,919.63 32,892.00 33,130.09 46,724.31 60,867.26 59,478.92 63,311.87 120,885.84 134,339.63 152,327.60 165,660.47 164,973.80 143,148.94 Weekly Cost Per Cent, of per Capita. Kecoveries. $3.14 48.88 3.85 43.92 3.70 57.34 4.61 49.16 6.09 45.53 6.16** 46.56 G.30 48.65 12.50 46.34 13.81 41.77 16.50* 16.13 21.07* 18.82 19.72* 19.56 15.66* 13.63 * These five sums are copied from the reports. As derived from the figures in the two next preceding columns of the table, they should be, beginning at the upper one, $6.18, $16.93, $21.09, $19.82, and $15.73, according to our calculation. THE CUKABILITY OF INSANITY. 87 For the purpose of comparison with this certainly very remarkable history of the results of treatment at the oldest institution in Massachusetts, — an institution always ably conducted, and never stinted in its pecuniary resources, — I select some no less remarkable statistics which have recently been received. The comparison re- veals a contrast so notable, that one may well exclaim, — " Look there upon that picture and on this." The Journal of Mental Science for January, 1878, contains a review of the first report of Dr. F. W. Skae, who has recently been appointed inspector of the asy- lums for the insane in the Colony of New Zealand. From this we learn that within that infant colony there are already no less than eight asylums, containing a total of 783 patients. The largest has 235, and the smallest, 4. There is " one insane person in asylums to every 509 of the population ; " but from defects of structure, or other objectionable features, those asylums furnish "satisfactory accommodation" for only 270 patients, although occupied, as above stated, by 783. All of these receptacles are " utterly deficient" in land, and their superintendents are not medical men. Of one of them, Dr. Skae says, " The condition of the patients, generally speaking, is deplorable. The great majority of them are simply prisoners, who are not, and in the present circumstances of the asylum cannot be, sub- jected to any system of treatment, curative or palliative. They have neither occupation nor amusement." Of another, — " parts of which (he thinks) were expressly constructed conformably to the ' wild beast theory of insanity,' " — he describes one room as " a cell, remote 88 THE CUEABILITY OF INSANITY. from supervision, badly lighted by a small barred window near the roof, having a sloping floor, with a drain to carry off urine, and furnished with a fixed privy, and a straw bag for a bed, and having a slit in the wall through which food can be pushed." These partial descriptions are here quoted for the purpose of emphasizing the results obtained in those asylums. " The ratio of recoveries to admissions," writes Dr. Skae, "is 13 ^^er cent, higher than in the Scotch and Irish asylums, and 23 pe?^ cent, higher than in English county and borough asylums.''^ " Their death-rate," remarks the reviewer, " was 6.70 per cent, on the average number resident, and 4.49 per cent, on the total number under treatment, being about 4.50 per cent, lower than in England.^'' It is no cause for marvel that the reviewer, in re- producing these statistics of recovery and mortality, says, " Here are facts for our pessimists." Yea, verily ! and it would be interesting to know what the optimists have to say about them. If within those rude colonial receptacles, over-crowded, and, in some portions, of a " quite disgusting description ;" where, in the patients' rooms, they have sloping floors, " with a drain to carry off urine ;" where the patients '' have neither occupation nor amusement," and are not "subjected to any system of treatment, curative or palliative," — if, in these places, the proportion of recoveries is so much larger, and the proportion of deaths so much smaller, than in the asylums of Great Britain, in which are found all the appliances of the most recent science, and all the comforts suggested by an enlightened humanity, is it not — let it be asked in sorrow, — is it not high time, so THE CURABILITY OF INSANITY. 89 far as results are concerned, for all of us to stop talking of the great improvements in the treatment of insanity, and for the people of some parts of this country to ask for the quid pro quo for the money which has been poured like a deluge upon some of the recently-erected hospitals for the insane ? DiSAG-EEEMENT OF DocTOES. — In the First Study mention is made of the fact that each person has his own standard of insanity, and that this standard de- pends, to a great extent, upon the constitution and the temperament of the individual ; and a remarkable illus- tration of the difference of this standard in different persons, as exhibited in the reported cures of a hos- pital for the insane, was there presented. A still more impressive exhibition of it is seen in the foregoing- statistics of the McLean Asylum, where, as will soon be perceived, this constitutional characteristic will, in large measure, explain the diminution of reported recoveries, although it may not account for the non- increase of recoveries under the enormously enlarged disbursement of money. Dr. Bell's proportion of recoveries, in 1840, was forty-eight (48.38) in the hundred. There was no great reduction of this proportion during the lapse of a generation. Even as late as 1867 the reported re- coveries were as high as fifty (50.56), and in 1869 almost forty-two (41.77), in the hundred. The asy- lum was then under the sujoerintendence of Dr. Ty- ler. In March, 1871, Dr. Tyler resigned, and was soon succeeded by Dr. Jelly. The statistics of admis- sions and recoveries at the asylum during the last seven years of the administration of the former, and the 7 90 THE CUEABILITY OF INSANITY. first seven years of that of the latter, are shown in the subjoined table : FIRST PERIOD. 1 SECOND PERIOD. Year. Admis- sions. Recov- eries. Per Cent, of Recoveries. Year. Admis- sions. Recov- eries. Per Cent, of | Recoveries. 1864 1865 1866 1867 1868 1869 1870 101 82 103 89 92 108 79 42 38 46 45 34 51 33 41.48 46.34 44.66 50.56 36.95 47.22 41.77 1871 1872 1873 1874 1875 1876 1877 75 93 92 75 85 92 110 21 15 19 20 16 18 15 28.00 16.13 20.65 26.66 18.82 19.56 13.63 Totals and Average. 654 289 44.19— Totals and Average. 622 124 19.94 The number of patients admitted (654) in the course of the first period was only thirty-two larger than that of the second period (622); but the number of recover- ies (289) was more than twice as great. The percentage of recoveries in the first period was 44.19 — , and, in the last, only 19.94 — : in other words, the proportion of recoveries of the first period was to the proportion of recoveries of the last period as 221 to 100, or as 100 to 45.24. It is impossible that, just at this juncture (1871), there was, in the character of the malady under which the persons received at the McLean Asylum were suffering, any sudden alteration sufiicient to explain this remarkable discrepancy in results. There is, in- deed, so far as appears, no reason for a belief that there was any such alteration. Furthermore, no man who has experience in the treatment of the disease, and who is acquainted with the superintendents of the two periods, would think of attributing the discrepancy in recoveries THE CURABILITY OF INSANITY. 91 to a difference in the medical sagacity and skill of those superinten d ents. Under the circumstances of the case, our only re- source for an explanation of the surprising difference in the proportion of reported recoveries is the " personal equation," or the diversity of characteristics in the con- stitution and temperament of the reporters. If this explanation be the true one, it necessarily follows that we must believe, that if a certain number of persons who have been insane and subjected to treatment be placed before two men equally competent for judgment, for a decision in regard to their mental condition, one of those men may adjudge recovery to two hundred and twenty-one of them, while the other will adjudge it to only one hundred. One of the obvious consequences of this state of things is, that it is impossible to form an accurate opinion of the comparative merits of different institutions for the insane from the recoveries at them respectively, as set forth in the annual reports. Although frequently done, it is absurd, at any time, to compare the recoveries at a private or corporate in- stitution at which epileptics, paralytics, imbeciles, and some other classes are never received, with those at a State institution which is compelled to admit all classes, and attempt, from this comparison, to judge of those institutions in respect to general excellence, or adapta- tion to the purpose to which they are devoted. The restricted and the unrestricted cannot justly be com- pared : they may more properly be contrasted. But, even in regard to institutions precisely alike in respect to the reception of patients, it has been shown 92 THE CURABILITY OF INSANITY. that men differ so widely in their estimate of what con- stitutes recovery, that it is the sheerest folly to base an opinion of comparative merit upon the alleged recover- ies ; for although, at the hospital A and the hospital B, the actual amount of improvement in the mental condi- tion of the patients may be precisely equal, yet the superintendent of A may report twice as many recov- eries as the superintendent of B. Supporters. — Inasmuch as all that is contained in the foregoing Studies was written under a strong con- viction that I was developing an important truth, a truth which would become the corrective of a prevalent, most glaring error; and inasmuch as all the elements of the argument have been drawn from the reports of asylums and hospitals, and the other works of authors who have written upon the subject, I have neither doubted the propriety and utility of the work, nor feared, in the least, that the argument could be over- thrown, or its conclusions disproved. The facts embod- ied in those conclusions are, however, so different from that which, in this country, had almost universally been accepted as truth for nearly half a century, that I must confess to an impression that I should stand compara- tively alone, with but few who were prepared to agree with me, and fewer still to extend their support. It is a source of great satisfaction that this impression has been proven to be false. The Second Study contains ex- tracts from approbative letters received from physicians and other persons interested in the subject. It is pro- posed here to add a few others, as illustrations of the spirit in which the essays have been received. A physician never connected with an institution for THE CURABILITY OF INSANITY. 93 the insane, but who is thoroughly conversant with the literature of the disease, and who is himself a somewhat prolific author upon the subject, writes as follows : " It had not escaped my notice that the large number of reported cases of recovery in the annual reports of the insane hospitals throughout the country were incon- sistent with the apparently rapid increase in the number of the insane, — an increase out of all proportion to that of the population, and for which there seemed to be no good reason, if this large proportion of cures were per- manent ones ; but your demonstration, that the actual permanent cures do not exceed twenty-five or twenty- six per cent., is none the less startling because it ex- plains the difficulty to which I have alluded. It is a sad comment on the progress of medical science in the art of healing, that we can as yet cure but one-fourth of the cases of insanity. I doubt if the proportion is much larger than it was at Gheel, in the days when the legend of the interposition of St. Dympna was fully believed, or when the monks of the Pyrenees relied upon the restoring effects of pure air and perfect quiet. I have no doubt of the truth of your deductions, and might plead, in extenuation, that insanity in America is more violent and unmanageable than in Europe (which I doubt not is true), but for the fact that your best statistics are from English and Scottish sources." Another physician, probably not so deeply read upon the subject as the author of the foregoing extract, but who, in an article relating to insanity written within the last year, had asserted that seventy per cent, of recent cases can be cured, makes the following evidently sincere avowal : 94 THE CURABILITY OF INSANITY. "Allow me to tliank you for your monograph. on the Curability of Insanity. I must acknowledge myself to have held an erroneous idea concerning the percentage of cures. Your exposition lays bare a glaring self- deception on the part of many, myself included. I am truly thankful to have been undeceived." A gentleman of broad culture, not a physician, but much interested in the subject of insanity, and for some years a member of the board of trustees of a large State hospital for the insane, says, — " Allow me to thank you for continued remembrance in sending your Twenty-second Report,* received yes- terday. I have read it this afternoon, and am greatly pleased with its truthful, fearless spirit. Your statistics and quotations are opening the eyes of those interested in the subject of insanity. If they are depressing to those who carry any portion of responsibility in care for the insane, it is the fault of the dire facts, and is not yours." Thus far for voices from this side of the Atlantic. Let us turn to some of those from Great Britain. And here it may be remarked, that, were this little work in- tended for physicians alone, the mere names of the au- thors of the remaining extracts would be their sufficient recommendation ; but since its circulation will be, to a considerable extent, among non-professional men, and members of other professions than that of medicine, some mention of their positions will not be out of place. What says England, as represented by Dr. Daniel Hack Tuke, joint author with Dr. Bucknill of " The * Containing Study Second. THE CURABILITY OF INSANITY. 95 Manual of Psychological Medicine," the standard gen- eral treatise upon insanity for all English-speaking people ? — " I ought to have expressed my obligations before for the pamphlet on ' The Curability of Insanity/ * which I have read with much interest. It is a valuable addi- tion to our literature, and such a setting forth of the sub- ject has been long required ; but it is an unpleasant task to do anything which even seems to render the curabil- ity of insanity less hopeful than it is," And the new edition of the aforesaid manual contains the following paragraph : " The fallacy of taking the recoveries of cases, instead of persons, has been ably insisted upon and illustrated by Dr. Earle, in a pamphlet on ' The Curability of In- sanity,' which is deserving of serious study by the su- perintendents of asylums in Britain as well as in the States." The next extract is from Scotland. A few short weeks ago it might have been presented as a voice from the living ; but it now, unhappily for humanity, comes as a voice from the dead. It is from Sir James Coxe, a man of great eminence in the medical profession, for many years a deeply interested and active member of the Scottish Board in Lunacy, and the author of several monographs upon insanity : " I have read it with much interest, and regard it as a most valuable contribution to the statistics of insanity. It cannot fail to exercise a powerful influence in neutral- izing that spirit of inflation, which, I am sorry to think, * Study First. 96 THE CURABILITY OF INSANITY. is a too prevalent characteristic of writers on this branch of medicine. The merits of superintendents of asylums are already sufficiently great, witjbout the adventitious glory of questionable success." In conclusion comes another Scottish authority, of no less eminence than that which next precedes. It is that of Dr. W. A. F. Browne, long known as the emi- nently successful superintendent of the Crichton Royal Asylum at Dumfries, and subsequently as a member of the Commission in Lunacy, and for a generation of years as one of the ablest of writers upon psychological subjects : " Although I differ from you upon one aspect of the subject of your paper, which may, to a considerable ex- tent, be accepted as an exposition of the ^Incurability of Insanity,' I regard your argument as most lucid and logical, and as presenting the matter treated of in a new and most striking light. " I entirely concur with you, that the ratio of cura- bility has depended, and will continue to depend, upon the standard created by the mental constitution of each superintendent, unless, indeed, an extern expert be called in to adjudicate in each case. " I have always demurred as to the accuracy of both Burrows and Woodward, even after giving credit for all the advantages and deductions which were claimed ; but I was more than staggered by the j)ractice which you reveal, and most properly denounce, of calculating the proportion of cures on the discharges ; although I al- most rejoiced over the explanation thus afforded of the ninety per cent., hundred per cent., etc., of cures, which seemed to attend your labors in America, and which THE CURABILITY OF INSANITY. 97 excited the envy and despair of my confreres and of myself. I am not aware tliat this mode of estimating success has found imitators with us. " The process by which you eliminate the numerical truth, by taking five years at different periods of what may be called an asylum curriculum, is, to my mind, demonstrative, and brings out nearly the figures to which we in England are now accustomed. " Your co7iclusions appear to me, upon the whole, im- pregnable. " Where I venture to differ from you is, that we must continue to calculate upon cases, and not persons. " Permit me, after this bold attempt to criticise, to express my unqualified approbation of your disquisi- tion." Those portions of the foregoing extracts which are here printed in italics were not emphasized in the origi- nals. After the assertion that " we must continue to calcu- late (recoveries) upon cases, and not persons,^'' Dr. Browne proceeds to give his reasons therefor. Those reasons are cogent and convincing ; but the doctor mis- takes my position. Nowhere in my essay is it asserted that the calculation of recoveries should not be made upon cases. I have always p)ursued that method, and I do not 2^erceive in what ivay it can be avoided. All that I have insisted on is, that the reports of recoveries shall be accompanied by an explanation by which the reader can learn whether those recoveries are from first attacks, or from attacks varying from the second to the thirtieth, the fortieth, or the fiftieth ; whether, if you report ten recoveries, it is to be understood that ten different per- 98 THE CURABILITY OF INSANITY. sons have really recovered, or merely that one person has recovered from ten successive attacks. The inability to convey this information is the grand fault in the gen- eral method of reporting, and by this fault public opinion has been grossly misled. This subject very naturally leads to what follows. The subjoined preamble and resolutions are sufficient proof that a no inconsiderable part of the physicians engaged in the specialty not only perceive the imperfec- tion of the general method of reporting recoveries, but are prepared so to alter that method as to avoid such errors in the future. They were introduced by the present writer, and adopted, in December last (1877), by the New England Psychological Society, an associa- tion of the superintendents of the regularly organized institutions for the insane in the States east of the Hud- son Kiver : " Whereas, The method generally heretofore pursued in reporting the recoveries of patients at the institutions for the insane, by its avoidance of a definite statement of the repeated recoveries of the same person in cases of periodical or recurrent insanity, has been largely instru- mental in imparting to the general reader, and particu- larly to persons outside of the profession who are specially interested in the subject, an erroneous opinion of the curability of persons afflicted with mental disor- der; and "Wheeeas, As a result of that erroneous opinion, computations have been made in political and social economy, based upon an assumed proportion of curables among the insane, which is evidently far too large ; and THE CUEABILITY OF INSANITY. 99 " Whereas, The attainment of truth, and not the dissemination of error, is the true object of all statistical science : therefore '^Resolved, That, in the preparation of published reports, this Society recommends the adoption of some method by which that erroneous opinion may be cor- rected, and in the future prevented, " Resolved, That, without prescribing or suggesting a definite formula, it is recommended that a clear exposi- tion should be made of the facts in relation to the following points : " 1st, In regard to patients admitted in the course of the year : the number admitted for the first time, and the number of re-admissions, specifying the number who have been received twice, thrice, four, and any greater number of times, and also the number who had previously been discharged recovered ; specifying, like- wise, the number who had recovered once, twice, thrice, and any greater number of times. "2d, In regard to patients discharged in the course of the year : the whole number of recoveries, specifying the number of those who recovered for the first time, as well as of those who recovered for the second, the third, the fourth, the fifth, and any time still higher in the scale of numbers. ^^ Resolved, Furthermore, that the true import and value of the statistics of any institution for the insane can be attained in no way other than by an analysis of the results, in which are shown, not alone the number of persons who recovered once, but the number of those same persons who recovered twice, thrice, four, five, or any higher number of times ; and that any collection 100 THE CURABILITY OF INSANITY. of statistics which has not been subjected to such an analysis is of comparatively little value." It appears to me that these resolutions constitute a step in advance in the right direction. The Vermont Report. — As this article is in course of preparation I receive a copy of the report of the Vermont Asylum for the two years ending July 31, 1878. As I open it to the section on Recoveries, I find that, with " the courage of his convictions," Dr. Draper gives the explanation called for in the foregoing resolu- tions. For the first time in the forty years of the existence of that institution is the reader of its reports enabled to obtain that understanding of the results of treatment, without which no accurate opinion of the importance of those results — as viewed in relation to the disease, or to either medical, political, or social science — can by any possibility be formed. " Of the number discharged," says the report, " fifty- two — thirty-six men and sixteen women — recovered. This is a fraction over 31 per cent, of the number ad- mitted. Of these, twenty-eight recovered from a first attack, nine from a second, three from a third, four from a fourth, two from a fifth, two from a sixth, one from a seventh, one from a tenth, one from a fourteenth, and one from a fifteenth." What a flood of light the third sentence of this para- graph throws upon the first! and not upon that alone, but upon the medical history of the hospital from the time of its origin. Of the fifty-two recoveries only twenty-eight, or two more than one-half, were from the first attack. The remaining twenty-four were of pa- THE CUKABILITY OF INSANITY. 101 tients who had previously left the hospital " recovered" from one to fourteen times each. Those twenty-four persons, as will be perceived by a brief computation, have given one hundred and eleven recoveries to the statistics of insanity, and it is not at all improbable that they will yet give as many more. It is very cer- tain that their future contributions will be large. Thus we have another evidence of the truth, that wherever and whenever light is permitted to break in upon the darkness of the statistics, in gross, of the in- stitutions for the insane, the revelation comes forth, that a large proportion of the recoveries — and the older the institution the larger is the proportion — are merely the expressions of intermissions in the disease of a com- paratively few persons who pass their lives in oscillating between their homes and the hospitals. And once more are we impressed with the folly of any attempt to illus- trate any important subject by the crude, unanalyzed statistics of the hospitals, or to deduce from them any conclusion or opinion relative to any of the great social problems of the day. Dr. Luther V. Bell's Prediction. — It will be recollected that, whatsoever might have been the incen- tives to the production of the essay upon the curability of insanity, one of the objects gained by it was the justification of an asylum in a neighboring State against an attack from a prominent officer of the government of that State, one of whose condemnatory allegations was, that the proportion of recoveries in these latter years has been less than in the earlier history of that asylum. And, in view of said allegation, it was written in that essay, "The declarations of the earlier superintendents 102 THE CUHABILITY OF INSANITY. are returning, like boomerangs, to spend their ultimate force upon their promulgators, or . . . upon the persons now standing in tlie places of their promulgators."* This was written without any knowledge, or, at least, any recollection — for I must have read it thirty-seven years ago — of a paragraph in one of Dr. Luther V. Bell's reports of the McLean Asylum, published at the time (1841) in which there was a general rivalry among the superintendents for the production of the highest proportion of recoveries, and but two years prior to the announcement at the hospital at Columbus, Ohio, that the per cent, of recoveries on all recent cases discharged at that institution in the course of the preceding year was one hundred. "As things now are progressing," wrote Dr. Bell, " there is infinite danger that the public mind may arrive at such views and expectations as to the cura- bility of insanity as will eventually react most unfavor- ably on our successors in these holy though arduous avocations, if not upon ourselves." The danger foreseen by that sagacious observer was not averted, and the identical form of public opinion which he feared was eventually produced. It is due to the memory of the very able and amiable prophet that his prophecy should be remembered. * See ante, page 62. STUDY KOURTM. (WRITTEN IN 1879.) Within the last three years, several superintendents have begun to give such explanations of the recoveries reported by them as may prevent the false inference in regard to persons heretofore alluded to, and consequently act as correctives of the erroneous public opinion. These explanations have revealed a state of things which shows that it is no cause for marvel that the public mind has been deceived upon the subject. For example, at the New Hampshire Asylum for the Insane, in the official year 1878-79, there were twenty-seven recoveries ; but Dr. Bancroft so arranges them, in tabular form, that we learn that only eleven of them were recoveries from a first attack. Sixteen of the persons had previously been reported recovered, — two of them once each, eight of them twice each, one of them four times, one of them eight times, one of them nine times, and one of them thirty-five times. After this last reported recovery, the total of the reported recoveries of these sixteen persons is ninety-two. This is a remarkable proportion of recoveries subse- quent to the first, and, undoubtedly, larger than that of most of the hospitals. The New Hampshire Asylum is among the old institutions, and these secondary recover- ies 104 THE CURABILITY OF INSANITY. ies increase in number with the advancing age of the hospital. But, in the face of such facts as these ex- planations reveal, those superintendents who do not thus explain the recoveries reported by them, need not be surprised if it should come to be believed that they are quite willing that the deception of the public mind should be continued. In the Second Study, surprise was expressed that some method of giving the reader of their reports a correct understanding of their reported recoveries in this respect had not been adopted at the British asy- lums. Among the reports received from them in the course of the last year, there are two in which some- thing of the kind has been introduced. At the Prestwich Asylum, in 1878, there were 214 recoveries. The su|3erintendent. Dr. H. Booke Ley, writes, in relation to them, that "one hundred and seventy-five had never before been treated in this asy- lum, and had therefore recovered from a first attack ; of twenty-five, this was the second admission ; of eight, the third admission ; of two, the fourth admission ; of two, the fifth admission ; of one, the sixth admission ; and of one, the seventh admission. The recorded condition, when discharged, of the thirty-nine who had ^^reviously been under treatment in this asylum, was, recovered in thirty-three instances, and improved in six instances, — consequently, ninety-two recoveries have been contrib- uted to the statistics of this asylum by these former residents." This, so far as I am informed, is the first exposition of the kind in England. W. H. Garner, Esq., Medical Superintendent of the THE CUEABILITY OF INSANITY. 105 Clonmel District Asylum, Ireland, in his report for 1878, says, " The discharges amounted to thirty-one of both sexes, being an average (percentage?) of over thirty-five on admissions. Of these latter, however, I am bound to say, seventeen were relapsed cases ; so that, as has been well pointed out by Dr. Pliny Earle of the State Lunatic Asylum at Northampton, U.S.A., the percentage of recoveries on admissions must be taken cum grano salisJ' Of the thirty-one patients discharged, twenty-eight were reported recovered, and three improved. Please observe the noteworthy fact, that, while twenty-eight were discharged recovered, seventeen were received who had previously been discharged recovered. The excess of recoveries sent out into the world, over the recoveries which the world had sent back, was only nine. We will now enter upon an exposition to which the careful attention of all persons interested in the subject is especially invited. How dry soever may be its as- pect, let them give it a thoughtful reading, and it will not be surprising if they discover that they have been amply repaid. It is the End that Crowns the Work. — In a recently published pamphlet entitled " Recoveries from Mental Disease," which will receive more prolonged attention farther on, the author, Dr. Isaac Pay, writes as follows : " AVhile it appears that once almost every patient recently attacked recovered, our statistics show that now, taking our hospitals together, hardly half of them have been so fortunate." The object of this section is to recall to notice a few 106 THE CURABILITY OF INSANITY. of those recoveries of the insane which, took place not less than thirty-five years ago, at a time included in that period to which Dr. Ray alludes as one that was so exceedingly favorable to restoration from mental disor- ders. We may thus, perhaps, be enabled to ascertain the true character of those recoveries. In an examination, a few months ago, of a reprint, in 1863, of the previously published reports of the Illinois Hospital for the Insane, I met a table copied from the report of the Worcester Lunatic Hospital for 1843, and republished in connection with a memorial by Miss Dix, for the purpose of showing the remark- able advantage, pecuniarily, of the treatment of insanity in its early stages. It presents two columns, or series of cases, twenty-five in each. Those in the first column were chronic and incurable; those in the second were recent, and had been discharged — all of them "recov- ered" — from the said hospital, in the course of the official year covered by the report. The official year at that time ended with the 30th of November, and not, as now, with the 30th of September. While studying the table, it occurred to me that it would be interesting to know the history, subsequent to their discharge, of the twenty-five persons who recov- ered after so short a period of treatment, and at so trifling an expense. Such was the inception of this chapter, and this the cause for the selection of the table of 1843, in preference to either of its predecessors. The first table of the kind was published, if I mistake not, in the Worcester report for 1837-38. The practice was continued for a series of years, and was adopted at various other institutions of the kind. Indeed, the THE CTJEABILITY OF INSANITY. 107 report for 1843, which contains the table, gives the results of similar tables at the State hospitals of Maine, Ohio, and Virginia. The table is here introduced, in order that the reader may obtain a clear understanding of the subject. TABLE SHOWING THE COMPAEATIVE EXPENSE OP SUP- POKTING OLD AND RECENT CASES OP INSANITY. From which we learn the Economy of placing Patients in Institutions in the early periods of Disease. Total Expense No. of the Old Cases. Present Age. Time Insane. at $100 a year before enter- ing the Hospi- pital, and S132 a year since ; last year, $120. No. of the Recent Cases dis- charged. Present Age. Time Insane. Cost of Support at 32.30 per week. 2 69 28 yrs. §3,212.00 1622 30 7 wks. $16.10 7 48 17 " 2,004.00 1624 34 20 " 46.00 8- 60 21 " 2,504.00 1625 51 32 " 73.60 12 47 25 " 2,894.00 1635 23 28 " 64.40 18 71 34 " 3,794.00 1642 42 40 " 92.00 19 59 18 " 2,204.00 1643 55 14 " 32.20 21 39 16 " - 1,993.00 1645 63 36 " 82.80 27 47 16 " 1,994.00 1649 22 40 " 92.00 44 56 26 " 2,982.00 1650 36 28 " 64.40 45 60 25 " 2,835.00 1658 36 14 " 32.20 102 53 25 " 2,833.00 1660 21 16 " 36.80 133 44 13 " 1,431.00 1661 19 27 " 62.10 176 55 20 " 2,486.00 1672 40 11 " 25.70 209 39 16 " 1,964.00 1676 23 23 " 52.90 223 50 20 " 2,364.00 1688 23 11 " 25.70 260 47 16 " 2,112.00 1690 23 27 " 62.10 278 49 10 " 1,424.00 1691 37 20 " 46.00 319 53 10 " 1,247.00 ! 1699 30 28 " 64.40 847 58 14 " 1,644.00 1705 24 17 " 39.10 367 40 12 " 1,444.00 \ 1706 55 10 " 23.00 400 43 14 " 1,644.00 ■ 1709 17 10 " 23.00 425 48 13 " 2,112.00 1715 19 40 " 92.00 431 36 13 " 1,412.00 1716 35 48 " 110.40 435 55 15 " 1,712.00 1728 52 55 " 126.50 488 37 17 " 1,912.00 1737 i 30 33 " 75.90 454 yrs. $54,157.00 635 wks. $1461.30 Average expense of old cases §2,166.20 Whole expense of 25 old cases 54,157.00 Average expense of recent cases 68.45 Whole expense of 25 recent cases till recovered 1,461.30 108 THE CURABILITY OF INSANITY. " The results of this table are so striking, and show so conclusively the importance of early admission to the insane hospitals, that many other institutions have instituted the same inquiry with similar results." (See Report of the Worcester Lunatic Hospital for 1843.) The report contains no assertion that the twenty-five recent cases were permanently cured ; neither does it allude to the probability, or the possibility, that any one of the ]3ersons might again become insane : hence the almost inevitable impression left upon the mind of the general reader by a perusal of the table would be that the twenty-five persons whose insanity was recent had never before been insane ; and that now, on the first attack of that disease, they were returned to their homes and to society fully and permanently restored to mental soundness. Indeed, the whole illustrative force of the table depends upon the assumption that they were per- manently cured. Furthermore, coupled with this im- pression would be the inference that, if the twenty-five persons whose disease was chronic had been taken to a hospital in the early stages of their mental unsoundness, they, too, would have been cured, — an inference the truth of which is wholly improbable. Then follows the practical deduction : If you send your insane friend early to the hosj^ital, his cure will cost but $58.45 ; if you neglect such early action, his support, while insane, will cost at least $2166.20. This deduction was, apparently, the whole ostensible object of the table. Taking, then, these twenty-five persons, so haj^pily, so quickly, and so cheaply withal, redeemed, by resto- ration, from one of the greatest ills that flesh is heir to, let us, while learning something of their antecedent his- THE CURABILITY OF INSANITY. 109 tory, go fortli with them from the hospital, and, so far as is practicable, follow them to the present time, if they still are living, or through their subsequent life, if that life be ended. The Twenty-five Recent Cases Recovered. — No. 1622. — This was a man, and this was his second attack of insanity, but his first admission to the hos- pital. He was discharged recovered, as in the table, May 1, 1843. Within about three weeks after the table was made,* and on the 20th of December, 1843, he was again committed to the" hospital. He remained a little more than three months, and was again discharged recovered March 25, 1844. He afterwards married, and it is believed that he has never been insane since he left the hospital. He was well, and living with his family, one year ago, as he probably is now. This information comes from one of his friends who visited him in 1878. No. 1624. — A woman. This was her second attack of insanity, the first one having occurred two years be- fore her admission to the hospital. The case is recorded as periodical and suicidal. She was discharged recov- ered, as in the table, June 21, 1843. An informant writes me, September, 1879, — "She is living, and is apparently in good health. I was not able to find out whether she ever became insane again or not." * It is assumed that the table was made on the 1st of Decem- ber, because the official year ended with the 30th of ISTovember, It could not have been made before the 28th of November, be- cause two of the patients represented in it were discharged on that day. Eight of the others were discharged in the course of that month. 110 THE CUKABILITY OF INSANITY. No. 1625. — A man. This was his second admission into the hospital. He was admitted the first time in July, 1840 He remained less than two months, and was discharged recovered September 17, 1840. He was discharged recovered the second time, as in the table, September 25, 1843. He was admitted the third time January 8, 1851, and nearly eight months afterwards, on the 29th of August, 1851, discharged recovered for the third time. His father and a son were insane. On his third admission, his case is recorded as " periodical, once in about four or five years." Hence it appears that there must have been one attack between the last two admis- sions to the hospital. Since the foregoing was written, I have learned that he had another attack in 1859, which lasted nearly a year. He was not taken to a hospital, but was cared for at home. After recovery he remained well until 1872, when he died of cholera morbus. His wife, and the son above mentioned, were patients at the Worcester Hospital, and the former died there. No. 1635. — A man. Insanity is hereditary in his family. He was discharged recovered, as in the table, October 11, 1843. He still lives and is in business. One of his relatives states (1879) that he "has not been insane since he left the Worcester Hospital;" and that he " is somewhat eccentric, but in no wise insane." No. 1642. — A man. The case is recorded as hered- itary and suicidal. Discharged recovered, as in the table, June 21, 1843. He was admitted again No- vember 19, 1844, and discharged recovered, the second THE CUEABILITY OF II^SANITY. Ill time, February 18, 1845. He was admitted the third time July 14, 1856, and died within less than thirty- six hours afterwards. On his last admission, it is recorded that a sister and a brother were insane, and that his son " hung himself one year ago." No. 1643. — A woman. Her father was insane, and she had had two previous attacks of insanity, " some twenty years ago, in two successive springs." After a residence of a little more than three months in the hospital, she was discharged recovered, as in the table, July 1, 1843. Her subsequent history is related to me, in dialogue form, by a correspondent who received it in conversa- tion with one of the nearest relatives of the woman, and a member of her family. Question. " Was she cured at the hospital ?" Answer. " Oh, no. She was just the same as she had previously been ; very despondent most of the time ; and she was constantly watched, — not that we feared her doing harm to others, but that she might harm herself." Question. " There was no change, after her going to the hospital, in her condition from what it had been previously ?" Answer. "Oh, no. She continued the same until her death, in 1854." Question. " What was the cause of her death ?" Answer. "She was run over by the cars. Most people thought it might have been by accident, but we could not tell." No. 1645. — A woman. This was her third admission to the hospital, and she was admitted four times after- wards. Her record is as follows : 112 THE CUE ABILITY OF INSANITY. First admission, August 2, 1838 ; discharged recovered January 10, 1839. Second admission, April 26, 1840; discharged re- covered November 6, 1840. Third admission, April 29, 1843 ; discharged recov- ered, as in the table, November 1, 1843. Fourth admission, May 31, 1845 ; discharged recov- ered June 23, 1846. Fifth admission, January 25, 1849 ; discharged re- covered May 8, 1851. Sixth admission, November 6, 1855 ; discharged re- covered May 13, 1856. Seventh admission, January 12, 1857 ; died at the hospital, of " old age," April 22, 1857. It is recorded, on her second admission, that her insanity was hereditary and periodical; and, on her fifth admission, that two of her brothers and one sister were insane. No. 1649.— A man. Admitted May 10, 1843 ; dis- charged recovered, as in the table, November 17, 1843. An informant writes that he is now living and well ; and that he "has shown no signs of his previous trouble for a number of years ^ As it is nearly thirty- six years since he left the hospital, this language would seem to imply that he has, shown signs of the disorder since the time of discharge. No. 1650.— A woman. Admitted May 11, 1843; discharged recovered, as in the table, September 12, 1843. She is still living, and " has never shown any symptoms of insanity since she left the hospital." No. 1658. — A woman whose mother was insane. She was admitted May 22, 1843, and discharged re- THE CURABILITY OF INSANITY. 113 covered, as in the table, July 27, 1843. In about two weeks after the table was made, and on the 13th of December, 1843, she was again committed to the hos- pital. She was discharged recovered, the second time, March 15, 1844. Since she left the hospital she has had two attacks of insanity, one of them following childbirth ; but they were not severe nor of long duration, and she was not taken to a hospital. She is now living and well, the mother of twelve children, ten of whom are living. No. 1660. — A woman,* whose mother and a sister were insane. This was her second term of treatment in the hospital. Her first admission was on the 14th of February, 1840. She remained until May 26, 1840, and was then discharged recovered. Her second admission — the one in the table — was on the 23d of May, 1843. She was discharged recovered, as in the table, August 23, 1843. After an absence of very nearly three years, she was admitted the third time, August 11, 1846. Within less than six weeks, and on the 17th of September, 1846, she was discharged recovered for the third time. She died at home, in 1849, " aged about twenty-eight years." No. 1661. — A young woman, whose insanity is re- corded as hereditary. She was admitted May 24, 1843, and discharged recovered, as in the table, No- vember 7, 1843. She was admitted again May 10, * Information received since the original publication of this study has enabled me to make the history of this case more accurate than it was at that time. 114 THE CUEABILITY OF IIs^SANITY. 1847, and discharged recovered, the second time, Sep- tember 30, 1847. Admitted the third time, December 3, 1849, and discharged recovered, the third time, March 20, 1850. I am informed that she " again became insane, and went to the hospital in New Hampshire ;" this was on the 14th of December, 1853. She was removed to the McLean Asylum, September 6, 1854, "where she re- mained, insane, until her death, July 5, 1867. Age, forty-four years." No. 1672. — A man. His disease is recorded as peri- odical in the table on page 24 of the Worcester report for 1843. He was admitted June 10, 1843, and dis- charged recovered, as in the table, August 18, 1843. He is now (1879) in the almshouse of a town, an officer of which writes to me as follows : " He never was cured. He is a foolish, harmless fellow. He was taken from the hospital (in 1843) to our almshouse, where he now is, in fair health, able to do very little light work ; simple and harmless when pleased, but ugly when crossed very much." No. 1676. — A woman. This was her third attack of insanity, and her second admission to the hospital. Her first admission was on the 24th of May, 1842. She was discharged recovered July 4, 1842. The second admis- sion, as in the table, was on the 13th of June, 1843. She was discharged recovered November 16, 1843. I am informed that she " remained well, after her return from the hospital, as long as she lived, which was not many years. I think she died about 1850." No. 1688. — A young woman. This was her fourth admission to the hospital. Her first admission was on THE CUKABILITY OF INSANITY. 115 August 20, 1836. She was discharged recovered Octo- ber 28, 1836. Her second admission was on January 19, 1839 ; discharged recovered July 4, 1839. Third admission, August 7, 1840; discharged recovered No- vember 25, 1840. At this admission her case was re- corded as periodical. Her fourth admission was on June 30, 1843. She was discharged, as in the table, recov- ered, for the fourth time, September 11, 1843. On the last admission it is stated that she was twenty-two years of age ; consequently she could have been but fifteen at the time of her first admission. After her fourth re- covery and departure from the hospital, I am informed that " she married, went West, lived with her husband some years, and was in an insane asylum out there," Having returned to Massachusetts, she was admitted into the Taunton Lunatic Hospital, March 18, 1864, and discharged therefrom, recovered, November 30, 1864. She was committed to the Worcester Hospital for the fifth time, August 5, 1865, and nearly two years afterwards, on the 28th of June, 1867, was discharged not improved. She was taken directly to the almshouse of the town which supports her, and there she still re- mains. " She works in the family, and is quiet," writes my informant ; " but at times is wild." No. 1690. — A young woman. Admitted July 5, 1843, and discharged recovered, as in the table, Oc- tober 21, 1843. About five years afterwards, in 1848, she died of consumption, not having been insane after she left the hospital. No. 1691. — A woman. Admitted July 8, 1843, and discharged recovered, as in the table, October 16, 1843. She died on the second anniversary of her discharge, 116 THE CURABILITY OF INSANITY. October 16, 1845. I am not informed whether her in- sanity reappeared. Probably it did not. No. 1699.— A man. Admitted July 20, 1843, and discharged recovered, as in the table, November 15, 1843. Of his subsequent condition, one of his nearest relatives writes (1879) as follows : " He has never been what we call insane since he came home ; but he has had spells of nervous excitement, when he would not sleep well, and then he would be full of his talk, and very nervous, for from four to six weeks. He is never violent, but easily excited if he is opposed. His nervous spells are generally once a year, not always, and then in cold weather. We feel anxious about him, fearing he may be insane." No. 1705. — A woman. Admitted July 25, 1843, and discharged recovered, as in the table, November 27, 1843. She was admitted the second time July 5, 1848, and dis- charged recovered December 5, 1848. Admitted the third time December 27, 1851, and discharged recov- ered, for the third time, July 16, 1852. On the 19th of July, 1856, she was admitted into the Taunton Lu- natic Hospital, where she died of consumption on the 17th of October of the same year. No. 1706. — A woman. This was her second attack of insanity, the first having occurred in 1823. She was admitted July 26, 1843, and discharged recovered, as in the table, September 26, 1843. She remained sane during the rest of her life, and died February 8, 1869, aged eighty years. No. 1709. — A young man. Admitted August 7, 1843. The record on admission states that "he has had previous attacks," and that " he has a brother THE CURABILITY OF INSAJSTITY. 117 insane now ;" and in the table on page 25 of the Worcester report for 1843, his case is called periodical. He was discharged recovered, as in the table, September 26, 1843. Ten days afterwards, on the 6th of October, 1843, he was admitted the second time. This must have been several weeks before the table was finished, because the official year did not end until November 30, and no less than thirteen of the other patients referred to in the table were discharged after the 6th of October. He was discharged the second time improved, Janu- ary 11, 1844. The records of this admission state that he " received an injury on the head many years since, from which he never entirely recovered." Although discharged the last time only "improved," he after- wards became so well that he married. He subse- quently left New England, and died somewhere in the Middle or the Southern States. It is not known that he ever had another attack of insanity after he left the hospital ; but a person who knew him well from early life, while he remained in New England, says that " he was always a weak-minded man." No. 1715. — A young woman. This was her second admission into the hospital in 1843, and she was ad- mitted three times afterwards ; and, on this admission, the case is called periodical in the table on page 25 of the report for 1843. Her record is as follows ; First ad- mission, April 8, 1843 ; discharged improved June 12, 1843. Second admission, August 16, 1843 ; discharged recovered November 28, 1843. Third admission, Feb- ruary 18, 1846; discharged recovered June 30, 1846. Fourth admission, November 13, 1846 ; discharged re- 118 THE CURABILITY OF INSANITY. covered June 15, 1847. Fifth admission, October 19, 1847 ; discharged recovered July 12, 1852. Her last term of residence in the hospital, as will be perceived, was more than four years and eight months. The record of her second admission says that she " has had fits," and that her "mind (is) not sound at any time." On the third admission it is recorded that the case is periodical, and that " for three weeks past (she) has had frequent convulsive fits daily." This case is as interesting as it is remarkable. Not- withstanding the foregoing history, she has since mar- ried, and borne two children, and is now living and well. No. 1716. — A woman. The earliest information we have of her is, that on April 30, 1830, at the age of twenty-one years, she was admitted into the McLean Asylum. She was discharged therefrom, July 31, 1830, much improved. She was admitted at the Worcester Hospital, as in the table, August 18, 1843. The rec- ords state that this was her fourth attack of insanity, and that each attack followed childbirth. She was discharged recovered November 28, 1843. On the 30th of April, 1849, she was admitted at the Butler Hospital, Providence, Rhode Island, where she remained seventeen months. She was removed thence, by her husband, October 8, 1850 ; and four days after- wards, on the 12th of October, 1850, she was admitted the second time at the Worcester Hospital. The rec- ords of this admission contain the following statements : " Insane for twenty years ; was here seven years ago ; now has not worked for more than three years." She died at the Worcester Hospital, of consumption, March 6, 1851. THE CUKABILITY OF INSANITY. 119 No. 1728. — A woman. Admitted September 7, 1843. The records state that she had had " occasional symp- toms of derangement for ten years," and that the dis- ease was hereditary. She was discharged recovered, as in the table, November 23, 1843. She was not ad- mitted again ; but I have learned through her relatives that no permanent benefit was derived from her treat- ment in the hospital. Says my informant, " She had been at home from the asylum but very few days before she was as bad as before going," and " her mental con- dition remained the same throughout life." She died of consumption November 5, 1854. No. 1737.— A woman. Admitted September 23, 1843. Her disease is recorded as hereditary, and she had a brother in the Worcester Hospital. She was discharged, as in the table, recovered November 22, 1843. She is still living. My informant writes of her as follows: "She was and is a Second- Advent woman. She believes that there is no salvation except through her creed, and in so far is a monomaniac in religion ; but is right in all other respects, and is in excellent health, as she has been always since her discharge from the hospital in 1843." And so we come to the end of the table, and — to an end of its argument. Time and history sometimes deal rudely with the most sanguine hopes and the most beau- tiful devices of men. The really surprising results of this investigation are suggestive of extended comment, but they must be dismissed by a brief reference to one or two points. 1. Of all the hitherto-published representations of the curability of insanity, the most unfavorable is that of 120 THE CURABILITY OF USTSANITY. the late Dr. Thurnam, whose general formula is given in Study First, page 60. Let us compare the results in these twenty-five per- sons, recovered at the Worcester Hospital, with that formula. According to the latter part of the formula, of the twenty-five persons, — (a) Ten should never have a second attack ; ib) Fifteen should have a second attack and perhaps more; and (c) Of ihQ^Q fifteen, ten should die insane. But we find that, in fact, admitting that the twenty- five reported recoveries were recoveries, then, under the most favorable construction, there were of the twenty- five— {a) Only seven who did not have a second attack ; {b) Eighteen had more than one attack ; (c) As so many are still living, it is impossible to say what will be the final result in regard to the number dying insane. But already ^ve have died insane at the hospitals, and two have died insane at home, making a total of seven. Two others are at almshouses, both hav- ing for a long period been incurably insane (they will undoubtedly die so), and one has died at home, who " was never well [sane] but a few months at a time." It is no exaggeration of the unpleasant aspect of these results, to say that they are no more favorable than Dr. Thurnam's formula represents. They are, indeed, less favorable, but their near approximation to that formula is somewhat remarkable. 2. Can our statisticians, philanthropists, and states- men longer be surprised that the hospitals do not put a stop to the increase of insanity ? THE CUEABILITY OF INSANITY. 121 Dr. Ray's Essay. — The " Recoveries from Mental Disease," from which. I have already quoted, was sug- gested by what has been written upon the same subject in the last two annual reports of the Northampton Lunatic Hospital (Studies Second and Third), and in a pamphlet entitled "The Curability of Insanity" (Study First) , which was read before the New England Psy- chological Society, in December, 1876. In regard to the essay as a whole, it is submitted that its statement and general representation of my argument are very inaccurate. At the opening of his argument, Dr. Ray says, " He (Dr. Earle) finds, as a general fact, that thirty or forty years ago, the proportion of recoveries, or cures as they are sometimes called, was much larger than it has been of late years. . . . This remarkable difference Dr. Earle attributes to two sources of error committed by those who reported the large proportion of recoveries. He then proceeds to state that these two sources of error are, in general terms, first, the temperament of the per- son reporting the recoveries ; and, secondly, the dupli- cate, and sometimes multiplicate, recoveries of the same person, whereby the recoveries of case are made to appear much larger than recoveries of 'persons." Now, so far from assuming the decreased number of recoveries as my premises or proposition, it was one of the objects of the paper to prove that there has been such a decrease. The attempt to prove it is not made until near the close of my essay ; and the fact of that decrease is made the seventh and last deduction from the whole discussion. Furthermore, strange as it may seem, neither of the " two sources of error" is anywhere alleged to be the cause of that reduction. 9 122 THE CURABILITY OF INSANITY. After having considered the two sources of error, and arrived at the conclusion that they do not satisfactorily account for the reduction in the number of cures, Dr. Ray says, "As, then, neither the temperament of the physician, nor the repeated counting of periodical cases, accounts for the larger proportion of recoveries in the earlier times, we must look for the explanation in an- other direction, and we shall find it in various agencies that have come into operation in later times." He goes on to explain, as if it were a discovery of his own, that these agencies are, in short, first, the admission to the hospitals of a larger proportion of incurables ; and, sec- ondly, the increased incurability of the disease. As before mentioned, my aim was to demonstrate that such a reduction or diminution has taken place, and not to show the causes of it. And yet those causes are briefly alluded to, on page 48 of " The Curability of Insanity," as follows : "If the causes of the general reduction of the proportion of recoveries, as stated un- der the seventh head, be sought, some of them will be found in, or inferred from, preceding portions of this discussion. "Among others are, first, the probable fact that, as institutions have multiplied, the proportion of chronic and incurable cases taken to them has increased; and, secondly, the not improbable fact that insanity, as a whole, is really becoming more and more an incurable disease. If it be true, as asserted by that accomplished scholar and profound thinker. Baron von Feuchtersle- ben, — and doubtless no one will deny its truth, — that in the progress of the last few centuries, as civilization has advanced, and the habits of the race have been con- THE CUKABILITY OF INSANITY. 123 sequently modified, disease has left its stronghold in the blood and the muscular tissues, and at length seated itself in the nervous system, it follows, perhaps, as a necessary consequence, that by a continuation of the cause of this change, the diseases of the brain and nerves must be- come more and more permanent."* And in Study Second, written in 1877, I say, "As hospital accommo- dations have increased, more and more of the large class of the chronic insane, who formerly remained among the people, are thus removed from their homes "f to the hos- pitals ; and I then proceed to quote from six authorities, showing that the same state of things is found in Great Britain. Thus, when Dr. Ray becomes dissatisfied with the two agencies erroneously assumed by him to be those to which I attributed the reduction of recoveries, and looks " for the explanation in another direction," he is not obliged to look beyond the writings which he 'is criticis- ing ; and four or five pages, near the close of his paper, are essentially only a mere elaboration of the ideas con- tained in the paragraphs just quoted from those writ- ings. Not only have I not alleged the " two sources of error" as causes of the reduction of recoveries, but I never, even in thought, assumed or believed them to be, to any considerable extent. The reporting of multiple recoveries certainly cannot be, because more have been reported of late years than thirty or forty years ago. The older the hospital, the larger the proportion of such recoveries. In regard to the other " source of error," * See pages 57, 58, ante. | Page 70, ante. 124 THE CURABILITY OF INSANITY. — the diversity of temperament of the different re- porters, — it may and it may not have tended to reduce the number as a whole, although there are instances in which it has appeared to reduce them, which are more striking than any in which they appear to have been increased by it. The only stated object of the essay on "The Curability of Insanity" (Study First) is, to ascertain whether the popular belief in the great cura- bility of that disorder is justified by facts. The general scope of that essay is asserted to be " a review of the subject of the curability of insanity."* This made the field of discussion so broad that the influence of temper- ament was legitimately mentioned, rather as a curious phenomenon, and hence a matter of general interest, than as one of the agents the influence of which has reduced the number of recoveries. And it is intro- duced, not as necessarily either a diminisher or an enlarger of recoveries, but as an " influence which has an important effect upon the proportionate reported restoration. "f In one instance that effect may be to re- duce, in another to increase. And I perceive no reason why its effect was any greater, either way, thirty or forty years ago, than it is now, other than its stimula- tion, at the former period, by the more active zeal and rivalry among the superintendents of the hospitals. So far it undoubtedly did exert an effect of increase, at that time ; and, as the stimulation has subsided by the less active rivalry, the effect is now towards a reduction. The remarkable instancej adduced in my pamphlet, in which one superintendent, at Worcester, reported, in * Ante, page 8. f Ante, page 14. | Ante, pages 16, 17. THE CURABILITY OF INSANITY. 125 a period of three years, ninety-five per cent, more recoveries than were reported by his successor in a pe- riod of the same duration ; and another instance, men- tioned in Study Third,* in which one superintendent of the McLean Asylum, during a period of seven years, repoited one hundred and twenty-one per cent, more recoveries than did his successor in a similar period, — both occurred within the last fifteen years. Even Dr. Ray, himself, not only acknowledges, in no less than three difierent places in his essay, that this difierence of temperament has affected the statistics of recoveries, but he enters into a somewhat extended argu- ment to prove that it has, and that, in the nature of the human constitution, it cannot be otherwise. Neverthe- less, he does " question whether it has had all the influ- ence attributed to it" by me, inasmuch as I "think it has sometimes led to a difference in the number of recoveries as reported, amounting to twenty-five per cent." Here, again. Dr. Ray does not quite accurately represent the author whom he criticises. I did not write " has sometimes led ;" but I did express my long- existing belief that " the number of cases reported as recovered might differ at least twenty-five per cent., according to the man who might act as judge of their mental condition."-)" But that is unimportant; the error of representation may be regarded as trivial. I still retain the belief; and for the benefit of persons who would prefer the concrete to the abstract, I will relate an anecdote. Within the last three months, in conver- sation with the superintendent of a large American * Ante^ pages 89, 90. f Ante, page 16. 126 THE CUEABILITY OF INSANITY. hospital, — a physician who has enjoyed the acquaintance of both of the ex-superintendents about to be men- tioned, — I said, " I believe that if, when Dr. Ray and the late Dr. Kockwell were in active service, it could have been possible for both of them, each in his re- spective institution, to treat the same patients, and to discharge them in the same condition, we should have had, for every seventy-five recoveries reported by Dr. Kay, no less than one hundred reported by Dr. Kock- well." Here is a difference, not alone of twenty-five, but of thirty-three and one-third per cent. ; and yet the superintendent to whom I spoke immediately over- endorsed the opinion with the remark, " I think there would be more difference than that." Hence as, in the days of Moliere, there were fagots and fagots ; so, now, there are opinions and opinions. The general misconception and misinterpretation of the writings under his review has necessarily vitiated many of the minor parts of Dr. Ray's argument ; and more than once in these he places me in an entirely false position. Thus, for example, he alludes to my use of the statistics of the Friends' Asylum at Frank- ford, and represents me as employing them for the pur- pose of accounting for the diminution of the number of recoveries in the course of the last thirty or forty years. I used them for no such thing. I used them for the purpose, primarily, of showing that, at any and at all times, in consequence of repeated admissions of the same person, the percentage of cases that recover is generally larger than that of persons that recover ; and, secondarily, by such showing, to illustrate the method by which the people at large have received the im- THE CURABILITY OF INSANITY. 127 pression that insanity is a far more curable disease tlian it really is. My argument, when using the Frankford statistics, was intended to be, briefly, as follows : The people have been taught to believe that from 75 to 90 per cent, of insane persons can be cured. The Frankford sta- tistics, the best we have, show but 65.69 per cent, of re- coveries. These recoveries are of cases, not of 2^^'^sons. Rejecting the readmissions, we find that the recoveries of persons were but 58.35 per cent. But these were not permanent recoveries. So many of the recovered per- sons were readmitted that the real proportion of persons who recovered permanently was only 48.39 j^er cent. Hence, instead of having 90, or 80, or even 75 insane persons permanently cured, in each hundred of the acutely insane, these statistics show that, at Frank- ford, only 48 (48.39) were so cured. Some persons will probably think that to be a pretty important difference. It would seem that Dr. Ray wrote his essay, not with my writings before him, but rather with a very imper- fect and confused memory of their contents, as derived from a hasty perusal of them at some period compara- tively remote. He makes a j^erfect muddle of my argu- ment ; and throughout his essay, he is almost constantly firing at a target of his own, all the time laboring under the delusion, and all the time leading his readers to believe, that he is firing at mine. It would occupy too much time and space to follow the doctor through the other similar mistakes and per- versions in his essay. There are, however, some other things that may be noticed. In allusion to the recov- 128 THE CURABILITY OF INSANITY. eries at Frankford, he says, " We doubt if in any other hospital the discharges have been at the rate of one patient recovered fifteen times; another, thirteen ; a third, nine ; a fourth, eight ; and a fifth, seven." " Nothing easier," writes Dr. Hack Tuke, " than to make sweep- ing statements without proof." It is no less easy to make a statement that rests upon a doubt. The doctor was evidently in a doubting mood when his paper was written. Permit me to dispel the doubt in, at least, this one instance. The total of recoveries of the five persons at Frank- ford \^ fifty-two. At the Hartford Retreat, five persons have been re- ported recovered as follows : one, fourteen times ; an- other, thirteen ; a third, nine ; a fourth, nine ; and a fifth, nine. Total recoveries of the five persons, ^/^y- four. At the Bloomingdale Asylum, as long ago as the year 1845, five men had been reported as recovered, — one of them, seventeen times ; another, thirteen ; a third, twelve ; a fourth, eleven ; and a fifth, ten. Total recov- eries of the five, sixty-three. At the same institution, at the same time, five ivomen had been reported recovered, — one, twenty times f an- other, nineteen ; a third, seven ; a fourth, seven ; and a fifth, six. Total recoveries of the ?\.yq, fifty-nine. Taking the highest five of both of these sex-groups of Bloomingdale patients, one of them recovered twenty times ; another, nineteen ; the third, seventeen ; the * This woman afterwards increased her recoveries to forty six, or only six less than the total of the five persons at Frankford. THE CURABILITY OF INSANITY. 129 fourth, thirteen; and the fifth, twelve. Total recov- eries of the five, eighty-one. At the Worcester Hospital, five men have been dis- charged recovered, — one of them, fourteen times; an- other, fourteen; the third, twelve; the fourth, nine; and the fifth, nine. Total recoveries of the ^nq, fifty- eight. At the same institution, five women have been dis- charged recovered, — one of them, twenty-two times ; another, sixteen ; the third, fifteen ; the fourth, four- teen ; and the fifth, eleven. Total recoveries of the five, seventy -eight. Uniting these two sex-groups of Worcester patients, and taking the highest five of them, one recovered twenty-two times ; another, sixteen ; the third, fifteen ; the fourth, fourteen ; and the fifth, fourteen. Total re- coveries of the five, eighty-one. At the New Hampshire Asylum at Concord, even among the twenty-seven patients discharged recovered in the official year 1878-79, there were five, the number of whose recoveries had been, — one of them, thirty-six times ; another, ten ; the third, nine ; the fourth, five ; and the fifth, three. Total recoveries of the five, sixty- three. The number of recoveries of these five persons is larger, by eleven, than that of the five at Frankford ; but of all the patients ever treated at Concord, the high- est five were as follows : one recovered thirty-seven times ; another, sixteen ; the third, eleven ; the fourth, ten ; and the fifth, ten. Total recoveries of the five, eighty-four. In every one of the instances here adduced, the '' rate" of recoveries is higher than that of the Frank- 130 THE CUE ABILITY OF IXSAjS'ITY. ford patients ; and in that of either the Bloomingdale Asyhun or of the Worcester Hospital, it is fifty-five per cent, higher ; while in that of the Concord Asylum, it is sixty-one per cent, higher. Should any vestige of doubt still remain, perhaps it may be obliterated by the fact that, at the Concord Asylum, ten persons have recovered a total of one hundred and twenty times, or an average of j)recisely twelve recoveries to each. This rate, however, is not quite so high as that of the above-mentioned ten pa- tients (five men and five women) at Bloomingdale, or as of the ten at Worcester. At the former the ten pa- tients recovered one hundred and twenty-two times, and at the latter one hundred and thirty-six times, — an average of over thirteen recoveries to each person. Again, Dr. Ray writes as follows : " Dr. Bell had good reason for saying, in his report of the McLean Asylum for 1840, ' that the records of this asylum jus- tify the declaration that all cases certainly recent, — that is, whose origin does not, either directly or obscurely, run back more than a year, — recover under a fair trial.' " It may be assumed that Dr. Bell had equally good reason for saying, as he did say, in 1857, a2323lying his opinion of the general curability or incurability of in- sanity to the case of an individual, — " I have come to the conclusion, that when a man once becomes insane, he is about used up for this world." In 1840, when he wrote the extract quoted by Dr. Bay, he had been but four years in the specialty, and his experience was com- paratively small. Seventeen years afterwards, when the latter expression of his opinion was given, that experi- THE CTJEABILITY OF IIS^SANITY. 131 ence was greatly enlarged, and it is not unlikely that he had had the ojDportunity to learn, in the later history of the patients who recovered in the earlier years of his residence at the McLean Asylum, the frequency, and often the permanency, of subsequent attacks, such as the reader may have learned in the foregoing history of the twenty-five patients discharged recovered from the Worcester Hospital in 1843. Though decided in his opinions, Dr. Bell's mind was open to conviction ; and when those opinions were altered, he had the inde- pendence, the manliness, to acknowledge it. In regard to repeated recoveries of the same person, Dr. Kay remarks, " The doctor (Earle) himself leaves it in doubt whether he would require us to report no case as recovered which has been so reported on any previous occasion. He certainly prescribes no rule to be observed." Dr. E,ay must have either overlooked or forgotten the paragrajDh of Study Third, from which the subjoined extract is taken : " Nowhere in my essay is it asserted that the calcu- lation of recoveries should not be made upon cases. I have always pursued that method, and I do not per- ceive in what way it can be avoided. All that I have insisted on is, that the reports of recoveries shall be ac- companied by an explanation, by which the reader can learn whether those recoveries are from the first attack, or from attacks varying from the second to the thirtieth, the fortieth, or the fiftieth ; whether, if you report ten recoveries, it is to be understood that ten different per- sons have really recovered, or merely that one person has recovered from ten successive attacks. The inability to convey this information is the grand fault in the gen- 132 THE CURABILITY OF I]!^SANITY. eral method of reporting, and by this fault public opinion has been grossly misled."* " Many of the instances of repeated recoveries men- tioned by Dr. Earle," remarks Dr. Ray, " were period- ical in their character. . . . These, certainly, were not recoveries, in any true sense of the term." But, in most instances, — in every instance but one, I believe, — they were reported as recoveries, and hence one cause of the prevailing misapprehension in the public mind in re- gard to the curability of insanity. The excej^tional in- stance is that of the cases at the Pennsylvania Hospital, in which I inferred that a patient had recovered thirty- two times, from the fact that he is reported to have had thirty-three attacks. But, in allusion to those cases. Dr. Bay says, " We learn from Dr. Kirkbride that no peri- odical case was ever discharged (at the Pennsylvania Hospital) as recovered." Referring to page 37 of Dr. Kirkbride's report for 1878, I find a table "showing the number of the attacks in 7867 cases," with the fol- lowing explanation : " This table shows, that of the en- tire number admitted, 5695 were suffering from their first attack of insanity, 1259 from a second attack, 421 from a third, and so on, till thirteen were laboring under a ninth attack when received into the institution. All these were distinct attacks of insanity, and, after the first, had been developed subsequently to recoveries from a previous attack or attacks of the disease." According to this explanation, a part of the cases which, in the First Study, are taken from the report for 1875 of the Pennsylvania Hospital, were, as I in- * Aiite, pages 97, 98. THE CURABILITY OF INSANITY. 133 ferred them to be, cases that had recovered from each previous attack. In the 94 persons admitted on the fifth attack, and the 172 persons on the fourth attack, the disease was not periodical, but every patient had recovered from each of his previous attacks. Tlie 172 persons admitted on the fourth attack had, consequently, previously recovered a total of 516 times, making the number of previous recoveries ^44: greater than the number of persons. That will do very well, without any of the periodical cases. It is sufficient to illustrate my point, that the reported recoveries largely exceed the number of persons that recover. Or if it be not suffi- cient, it may now be supplemented by the thirteen per- sons mentioned by Dr. Kirkbride in the above explana- tion, as " laboring under a ninth attack when received into the institution." These thirteen persons had already recovered eight times each, — a total of 104 recoveries. In all instances where the person has had ten attacks or more. Dr. Kirkbride classes the case as periodical; and, according to Dr. Kay, not one of these cases has ever been discharged as recovered from the Pennsyl- vania Hospital. But in all instances in which the num- ber of attacks has been less than ten, the case is not periodical, and the patient really does recover from each successive attack ; and, of course, when he leaves the hospital, is reported as recovered. This may be a good method of classification, but the propriety of its universal adoption is doubtful. It might lead to difficulty. Not every physician possesses that acuteness of mental vision by which, when a patient has apparently recovered from his second, third, fourth, or fifth attack, he can deter- mine the question whether that patient is going to have, 134 THE CURABILITY OF INSANITY. in all, nine attacks, or whether, on the contrary, he will have ten. If he cannot decide that point, he will not be able to classify the case as periodical or not periodical ; and if he cannot so classify him, he will not know whether to report him as recovered or not recovered! This would be greatly embarrassing. Again, supposing that, by a mistake not unlikely to occur, he should re- port a patient as recovered nme times in succession, and the patient should then have a tenth attack. Another embarrassment, from which there would be no relief but by letting those nine recoveries (like the sick man's reconciliation with his neighbor, in case the sick man should recover) " go for nothing," inasmuch as that tenth attack has proved that they were not recoveries ! It is even somewhat singular that, of the no inconsid- erable number of periodical cases at the Pennsylvania Hospital, not one of them has had less than ten attacks. It might reasonably be supposed that there would be at least one or two not farther advanced than the seventh or the eighth attack. In allusion to my remark, that " if a person have a thirty-third attack of disease, it necessarily follows that he had previously recovered from thirty-two attacks," my reviewer exclaims, " This is a tremendous jump at a conclusion based on the vague signification of a single word." My impression is, that if, to one hundred phy- sicians, it were asserted that a person has had jive attacks of insanity, the instant inference of ninety-and-nine of those physicians would be, that the person had recovered from each of the first four attacks. The hundredth and exceptional man would probably be Dr. Kay. But, be this as it may, it is questionable whether the two con- THE CURABILITY OF INSAK^ITY. 135 testants in this matter are quite old enough to begin to accuse each other of exalted skill in gymnastics. For one, I am perfectly willing that the audience shall de- cide which of the two was the greater leap, mine, in drawing the inference as expressed in the above quota- tion, or Dr. Ray's, in bounding from the beginning to the end of my essay, and mistaking one of my conclu- sions for my premises. In all that I have written upon the controverted sub- ject under consideration, I have intended constantly to represent, as a dominant idea, that public opinion has been greatly misled by the method of reporting recov- eries at the hospitals. Dr.- E,ay comes to my assistance in the pamphlet before me, from which I make the fol- lowing extract, the last two of the three series of italics being mine : " It may well be doubted whether the terms recovered, improved, much improved, have been of any use not more than balanced by their inevitable tendency to mis- lead the reader respecting the curability of insanity. But the pubhc have always wished to know particularly what the hospitals were doing, and, as often happens, thought that the information sought for was to be found in a parade of vague general expressions^^ Finally, so far as regards Dr. Ray's essay, it is main- tained and submitted that not one of the seven conclu- sions in Study First is either refuted or in any wise weakened by anything in the '^Recoveries from Mental Disease. ^^ SuppoETERS. — Under the peculiar circumstances by which I was environed at the time of the original pub- lication of the First Study, and which still exist to a 136 THE CURABILITY OF INSANITY. certain extent, I have considered it justifiable to pub- lish some of the comments which it has elicited from its readers. To those already given in the preceding pages are now added a few, selected from those which have been received within the last year, and several of them suggested by the Study which was written in 1878. I do it the more willingly in consequence of the inter- esting and valuable suggestions contained in some of them. No one of the writers resides in Massachusetts, and only two of them in the New England States. " I am greatly pleased," writes a physician who is a member of the board of trustees of a large State hos- pital, "with the proofs you have given that the per cent, of cures of the insane has been greatly overrated. There is indeed a wide distinction to be made between the cures of cases and the cures of persons.'''' The superintendent of a hospital in a remote State says, " I thank you for the result of your studies on the curability of insanity, as indicated by statistics. Your discoveries, I confess, were startling, and though a little unpleasant, are strongly supported by facts." A physician in general practice, but who has been connected as assistant-physician with two of the State hospitals, writes as follows : "Your pamphlet on the curability of insanity I wish particularly to thank you for. The picture you draw is dark, but gives intense satisfaction by the careful and truthful way in which it is drawn. If you cannot always cure, you do give much relief, and make hun- dreds comfortable who would otherwise have lived most wretched, much abused lives. Not only would I thank you for the courtesy itself, but also for the labor which THE CUEABILITY OF INSAIS^ITY. 137 you took upon yourself to present the truth to us in so comprehensible a form." The next extract needs no introduction or explana- tion : "After seven years on our Board of Charities and Corrections, on my second year of a new six years' term, not once have I had such clear exposition of my views of insanity, and practical views in reports of cures, etc., as in your '78 report," — Study Third. "As to the curability of insanity," says a physician greatly interested in the subject, but never engaged in the practice of the specialty, " I worked out a part of the problem a few years since, but did not dare publish my results, as I knew that, not being in an insane asy- lum, they would be scouted. The Australian illustra- tion is startling ; but then look at the recoveries in our city asylums, like New York and Flatbush and Phila- delphia." There is great good sense in the subjoined remarks of a physician who has not only read extensively, but thought profoundly, upon the whole subject of mental disorders and their treatment : " The views you have presented so ably, and con- firmed by such irrefragable testimony, cannot fail of having a powerful effect in stimulating the profession to seek for better methods for the treatment of the insane. It seems to me that there has been progress made in the pathology of insanity, though I am afraid very little in the treatment. Suj)pose we were to revert to the earlier practice in part, giving the jDatient less of cosseting and coddling, and more of open-air life and actual employ- ment for his muscles in daily toil, where there is a pos- 10 138 THE CURABILITY OF INSANITY. sibility that he can endure it. ... I have no sympathy with the mere theorists who are demanding constantly that we should have institutions established here on the model of Gheel, for they do not know what they are talking about; but this increasing incurability of in- sanity, with the constant increase in the number of the insane, is an opprobrium on the skill and ability of the profession which should be removed if possible. Lec- tures and processional walks, and chemical experiments, libraries, etc., are all very well in their way, but the amusement which appeals most powerfully to the insane patient is labor according to his strength ; especially if he is to be paid for it. ... I am aware that, with your large and admirably managed farm, and your other ap- pliances, you are doing much in this way ; but, with your severe winters in Massachusetts, is it not possible to do more in your workshops ?....! want to ask that you, who have had the courage to show the lack of success of the past treatment of the insane, should de- monstrate, as I believe you can, that there is a better way, not by establishing a commune of the insane, not by the cottage system, but by a more thorough open-air treatment and the successful extension of active employ- ment." A fit conclusion is found in the views of Professor Ordronaux, who is a teacher of psychology in its legal relations, as well as Commissioner in Lunacy of the State of New York : " You have presented some very striking statistics in relation to the mistaken curability of insanity. Our pathological investigations all tend to show that nerve- tissue is among the slowest to repair its lesions, and that, THE CURABILITY OF INSANITY. 139 even in cases of supposed repair, the quality of tlie new tissue is so far inferior to the original, that all functions dependent ujDon it must forever after be performed in a less perfect way. Under the shadow of these natural laws, it seems to me that much of what we call ' recov- ery' from insanity, consists only in a diminution of its most salient and obtrusive features, and that there remains behind a permanently weakened brain, ready to give way under any exceptional strain." STUDY KIKTH. (WRITTEN IN 1880.) Near the end of tlie First Study are seven conclu- sions, in the form of propositions, which it is believed are legitimate deductions from the preceding argument. It is now proposed to show, as nearly as possibly can be shown, by direct evidence, that each of those conclusions can be proved to be true, beyond all cavil or dispute, to any candid mind. Conclusion 1. — The reported recoveries from in- sanity are increased, to an important extent, by re- peated recoveries from the periodical or recurrent form of the disease in the same jDcrson. Many proofs of this are given in the First Study, but here we will present only five, some of which have been obtained since that Study was originally published : At the Frankford Asylum . . 5 persons recovered 52 times. Hartford Eetreat . . 5 " " 54 " Blooraiugdale Asylum . 10 " " 122 " Worcester Hospital . 10 " " 136 '' Concord Asylum . . 10 " " 120 " Consequently, the . . , .40 " " 484 '• The number of recoveries is more than twelve times as large as the number of persons that recovered. ConclusiojST 2. — The recoveries of persons are much less numerous than the recoveries of patients or cases. 140 THE CURABILITY OF INSANITY. 141 This is proved by the same statistics as conclusion No. 1. The number of persons is less than one-twelfth of the number of recoveries, — each recovery, of course, rep- resenting Q. patient, or a case. CoNCLTJSioisr 3. — From the number of reported recov- eries of cases, or patients, it is generally impossible to ascertain the number of persons who recovered. This, also, may be proved by the same statistics. The four hundred and eighty-four recoveries were published merely as recoveries, without any explanation. Conse- quently no reader of them could tell how many persons furnished those recoveries. The natural inference was, that there were four hundred and eighty-four, whereas there were but forty. CoNCLUSiOiSr 4. — The number of reported recoveries is influenced, sometimes largely, by the temperament of the reporter, each man having his own standard, or cri- terion, of insanity. This conclusion is not susceptible of absolute proof ; but it is a legitimate inference from the known diversity of organization, temperament, and mental character among men. There are, however, two instances, at least, in which statistics appear to warrant the conclu- sion. These are the singular results, under two suc- cessive administrations at the Worcester Hospital and the McLean Asylum, as detailed in Study First and Study Third. At the institution first mentioned, the percentage of recoveries in three years, under the first administration, was nearly twice as great as under the second ; and at the one last mentioned, in seven years, it was more than twice as great, or as 221 to 100. 142 THE CURABILITY OF INSANITY. Conclusion 5. — The large proportion of recoveries formerly reported was (a) often based upon the num- ber of patients discharged, instead of the number ad- mitted ; and (b) generally upon the results in a number of cases too small to justify the deduction therefrom of a general formula of scientific truth ; and (c) those pro- portions were evidently increased by that zeal and rivalry which frequently characterize the earlier pe- riods of a great philanthropic enterprise. {a) At a large proportion of the American hospitals, forty years ago, the ratio of recoveries was calculated on the number of patients discharged. {b) The most widely known of all remarkable per- centages of recoveries of cases of recent insanity — those of the Hartford Retreat, in 1827 — were based upon only twenty -three cases, of which twenty-two recovered ; and one of the others, — that of the Williamsburg, Virginia, Asylum, in 1842, — upon only thirteen cases, of which twelve recovered. (c) There are various evidences of the existence of that zeal and rivalry in the earlier history of the hos- pitals, which need not be mentioned here. Conclusion 6. — The assumed curability of insanity, as represented by those proportions of recoveries, has not only not been sustained, but has been practically disproved by subsequent and more extensive experience. The assumption was, that from 75 to 90 per cent, of the recent cases of insanity could be cured. The con- clusion is proved by many statistics, but most especially by those of the Frankford Asylum, based upon the treatment of 1061 cases, treated in the course of about thirty-nine years. Only 65.69 per cent, of these cases THE CURABILITY OF INSANITY. 143 recovered. But so many of these were tlie repeated recoveries, on readmission, of the same persons, that the percentage of persons who recovered was only 58.35. Many of these were not permanent recoveries. The actual proportion of persons who, after one recovery, were never readmitted, was only 48.39 per cent. Conclusion 7. — The reported proportion of recov- eries of all cases received at the institutions for the insane, has been constantly diminishing during a period of from twenty to fifty years. This conclusion is derived solely from the results of the table on pages 54, b^ of the First Study. In that table it is shown that, at twenty American hospitals, the average diminution of reported recoveries, in an average period of about twenty-five years, was from 46.08 to 34.26 per cent, of the admissions. So that for every hundred that recovered, on an average of twenty-five years ago, only a fraction over seventy-four (74.34) recover now. Worcester Statistics. — In the annual report for 1878-79 of the State Lunatic Hospital at Worcester, a new table was introduced, in which is shown, among other things, how many of the patients who were dis- charged as recovered within the year had recovered on former admissions. Forty-seven patients were dis- charged recovered, but only thirty-two recovered for the first time. Five recovered for the second time, six for the third time, two for the fourth time, one for the ninth time, and one for the tenth. Thus, fifteen of these patients have already been credited with fifty-five recoveries. But the report contains something of still greater importance. Dr. Park has continued the work, begun 144 THE CUEABILITY OF INSANITY. several years ago by Dr. Eastman, of analyzing the 11,000 cases admitted into that hospital prior to the 28th of September, 1875. He finds that the whole number of persons admitted was only 8204, while the number of readmissions was 2796. The readmissions are equal to one-fourth of the whole number of admissions, and to one-third of the whole number of persons. The recoveries on first admission were 3191, or only 38.89 per cent, of the persons admitted. The recoveries in all the readmissions were 1191, making the whole number of recoveries 4382. Some of the persons who were not well when first discharged, recovered on some subsequent admission. We are not informed how many there were of these. A series of tabular figures show how many patients were received, on readmission, each successive time, up to the twenty-third admission. The recoveries on each admission are also shown, and it is both interesting and instructive to perceive how the proportion of these recoveries increases, in direct ratio with the increase of the number of readmissions. The percentage of the recoveries, on each admission, is as follows : 1st adin ission, 38.89 13th admission, 66.66 2d '• 36.78 14th 88.88 3d u 46.66 15th u 57.14 4tb iC 45.81 16th n 75.00 5th " 55.45 17th 11 66.66 6th a 61.29 18th u 66.66 7th i.i 61.36 19th ii 50.00 8th li 60.60 20th 11 100.00 9th .1 62.96 21st a 100.00 10th a 62.50 22d a 100.00 11th '• 61.11 23d a 100.00 12th 71.43 THE CUEABILITY OF INSANITY. 145 These gradually swelling percentages are caused by the repeated recoveries of the same persons. The whole number of deaths was 1498, or 18.26 per cent, of the number of persons. This proportion is nearly three times as large as is generally shown in the annual statistics of the hospitals. Dr. Park concludes his remarks upon the work of analysis in which he is engaged with the following par- agraph : " It is a sad, and almost cruel blow to the worth of the earlier tables of this hospital, which gave 70, 80, and even 90 per cent, of recoveries, to know that deaths occurring within a few days of admission were not taken into account at all, but stricken entirely from the reports ; that many a patient who helped to swell the tables of recoveries to the large per cent, mentioned, returned again and again to this hospital, and finally died here ; that many went afterAvards to other hospitals, and finally died in them ; and that many more, after repeated admissions to this and other hospitals, died in the town or city almshouse, having been, to take the cold, utilitarian view which is the fashion of this world, ' a burden on their own property or that of their friends, or upon the public treasury,' from the time of their first admission to the hosjoital to their death." The doctor will fail to take the full advantage of .his opportunity, if, before he gets through with those sta- tistics, he does not give to the profession and the people a more valuable paper illustrative of the actual curabil- ity of insanity than any heretofore published in this country. In reference to the above-mentioned deaths, of which 146 THE CURABILITY OF INSANITY. no account was taken in making up the statistics, there is an explanation which should be known. The first superintendent at Worcester openly maintained that it was unjust to both the institution and its medical offi- cers, to throw upon it and them the responsibility or bur- den of a death, when they had had no reasonable oppor- tunity to prevent that death. This argument is plaus- ible, but it can be used only by one who contemplates the subject from a narrow and strictly professional point of view. A hospital for the insane, however, has other than mere medical relations with the people ; and it would generally be regarded as the duty of its superin- tendent to report every case of admission and every case of discharge, whether that discharge be by death or otherwise. A Voice from England. — At the last meeting of the British Medical Association, Dr. D. Hack Tuke read a paper before the Psychological Section of that society, " On the best Mode of tabulating Recoveries from Insanity in Asylum Reports," in which he comes essentially to the same conclusions, in respect to re- peated recoveries of the same persons, that have been arrived at in what I have written upon the curability of insanity. "All I object to," says he, " is allowing figures to go forward, year after year, to the public, representing the gross number of recoveries as the number of persons restored to society, able to resume their place as useful members of the community ; for, without some clearer mode of presenting the actual facts than at present obtains, they will believe that 100 recoveries represent 100 persons enjoying the use of their reason, instead of, THE CUKABILITY OF INSANITY. 147 in too many cases, oscillating between the world and the asylum. Then, in their ignorance of the tendency to the recurrence of insanity, they are astonished at the ever-increasing demands for new asylums, and the con- clusion, out of all proportion to the fact, that there has been an increase of insanity. Nor will these miscon- ceptions be dispelled till it is stated, in characters so legible that he who runs may read, how many of the published cures are only re-cures of relapsed cases." The paper closes with a summary, under five heads, three of which are as follows : " I. That the statistical tables in the reports of the asylums for the insane should contain a clear statement, not only of the readmissions (specifying the number for each person, and distinguishing between readmis- sions after recovery, improvement, etc.), but of the re- cures, showing separately the number of persons who have recovered. " 11. That the percentage of recovery given in these tables should be that oi persons recovered, calculated on persons admitted. " V. That the present plan of jumbling together, in the statistical table of recoveries, the gross number of cures and re-cures, is misleading, and occasions exag- gerated views as to the curability of insanity, and pro- portionate disappointment when the demand is made for additional asylums." The subjoined extract from Dr. Tuke's paper is in- troduced here as evidence that the experience with re- peaters in recovery, in the English asylums, is very similar to that in the institutions in this country. " I find that at the Hereford Asylum one patient was 148 THE CUEABILITY OF INSANITY. first admitted in consequence of a fifth attack, and recovered from that, and a sixth, seventh, eighth, ninth, and tenth attack. He had slighter attacks at home, not sufiicient to bring him to the asylum, in the inter- vals. Of this patient Dr. Chapman says, that, although counting six recoveries, he really did not recover at all. Another patient, admitted in consequence of a fourth attack, recovered from that, and from a fifth, sixth, seventh, eighth, ninth, tenth, and eleventh attack. Another, admitted for a second attack, recovered from it, and from a third, fourth, fifth, and sixth attack. Lastly, two patients, each admitted on the fourth attack, recovered from it, and from a fifth and a sixth attack. All these, and several others. Dr. Chapman has no doubt will return again and again. How can we call these ' cures' ? Is it not a misnomer ?" It is now (1880) but a few months more than nine years since Dr. Chapman very courteously showed me through the Hereford Asylum, then in the process of construction, and not very nearly completed. Yet in the intervening period it has been finished and opened, and had time to make the somewhat remarkable record above related. One of its patients, as will be seen, has recovered eight times, and had recovered from three attacks before his first admission there. Dr. Tuke gives formulas of new tables, by the use of which not only the readmissions, but the repeated re- coveries of patients, will be shown. There is good rea- son, not alone from this j^aper, but by other evidence as well, to believe that the time is not far distant at which the British asylums will remedy the very obvious defect in their numerical statistics. THE CUEABILITY OF H^SANITY. 149 There is one point in respect to which Dr. Tuke's views are so fully coincident with my own, that I de- sire to call attention to them. Many writers, in treating of the curability of insanity, have made comparisons be- tween that disease and others of severe form, such as fever, pneumonia, and rheumatism, maintaining that the former yields favorably to remedial treatment as often as any of the latter. Dr. Tuke says, " I cannot agree with those who hold that we should regard each cure of insanity in a patient in the same light as each cure of a physical disease, — pneumonia, for instance . ..." It seems to me that our experience proves but too clearly that the parallel is not a fair one, for the relapses after pneumonia and fever, when once cured, would be much less frequent than in mental disease ; and the patient himself would be generally a sounder man, 'physically, in the interval, than the re- cured lunatic is mentally. Besides, from the different functions of the organs attacked, the jDcrmanent con- solidation of a portion of one lung may allow a man to perform efficiently the duties of his position in life ; but the remains of an infinitesimal lesion of the brain may virtually inca23acitate him from the efficient performance of his duties in the intervals between the attacks." I gladly seize this opportunity to quote a still earlier expression of similar opinions by Dr. Strong, of the Asylum for the Insane near Cleveland, Ohio. In a discussion at the meeting of superintendents, at Provi- dence, in 1879, he said, " That insanity has, in modern times, changed its type, to some extent at least, there can be no doubt. I fail to see, however, in its recur- rence, an analogy with other diseases, — pneumonia, for 150 THE CURABILITY OF INSANITY. instance, — which has been claimed by some gentlemen who have already spoken. Insanity is a disease involv- ing the brain and nervous centres, — a disease which is, to a considerable extent, sui generis, and will not admit of close analogy to other diseases." It appears to the present writer that there is about as close an analogy between pneumonia and insanity as there is between a broken bone and a broken promise. A Voice from Scotland. — Within the last year Dr. W. A. F. Browne, of Scotland, has published a pam- phlet entitled "The Curability of Insanity, Psycho- logical Shadows," which contains much that is con- firmatory of the views expressed in what I have written upon the same subject. " Every superintendent," writes he, " must see in his registers cases which have been removed once or twice, or oftener, during the year ; and I can recall one up- right 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 per- centages. This course was pursued in all candor and honesty, not merely as that generally, if not universally, prevalent, but because the cure was perfect, if not per- manent, and because the law required it." In Scotland, as in the United States, it appears that among the " recoveries" at the lunatic asylums are many cases of " delirium tremens and pseudo-dij)Somania." Under the " Habitual Drunkards Act" inebriates could go voluntarily into an asylum, and leave it when they pleased. " It is known," says Dr. Browne, " that many of these inebriates adopted seclusion as the readiest THE CURABILITY OF INSANITY. 151 refuge from bodily indisposition or the social conse- quences of their errors, so that, when the malaise and the rejDentance had evaporated, they at once returned to the world and to their wallowing in the mire, but not until they had been honored by a certificate of recovery." In regard to the absolute curability of mental dis- orders, a fact or a truth not yet attained, the doctor expresses his opinion in the following words : " It is highly probable that at the present time, as when Thurnam wrote, ' In round numbers, of ten per- sons attacked by insanity, five recover and five die, sooner or later, during the attack. Of the five who recover, not more than two remain well during the rest of their lives. The other three sustain subsequent attacks, during which at least two of them die.' " And finally, the pamphlet records, in the subjoined extract, its author's verdict upon the custom formerly very prevalent in this country, and even now not wholly abandoned, of giving the percentage of recoveries on the number of patients discharged, and sometimes of deducting from the whole number of patients all cases of idiocy, epilepsy, and paralysis, and even all deaths, and calculating the per cent, of recoveries on the remainder. " It would be an insult to our existing convictions, and to the principles, which may be now pronounced catholic, regulating the estimates of the results of treat- ment in nervous diseases, to point out how utterly fal- lacious, decejDtive, and Utopian were such practices; but it is essential to our object to stigmatize them as subversive, on the one hand, of all correct notions as to 152 THE CURABILITY OF INSANITY. prognosis in mental disease, and, upon the other, of the remedial powers which can be exercised for its removal or amelioration." Scottish Patients of 1868. — There were 1319 new cases of insanity admitted into the asylums of Scotland in 1868. A table in the Report for 1879 of the Com- missioners in Lunacy for that country, shows the num- ber of recoveries, not only on the first admission, but on readmission, among those 1319 persons, in each successive year, to 1880. " It appears," says the report, " that the 1319 pa- tients admitted yielded 39 per cent, of recoveries within the first two years, and during the succeeding ten years only 16 per cent. It is to be kept in mind that one patient may yield more than one recovery, and it must not be concluded, therefore, that anything approaching to these projjortions ai^e permanent recoveries. Indeed, it has been ascertained that a large number of the re- admissions are drawn from the recovered patients. If the whole of the readmissions came from this source, the proportion of the 1319 admitted in 1868, who had recovered and had not been readmitted up to the pres- ent time, would be only 26 per cent. It may be be- lieved, however, that some of the readmissions were drawn from among the patients discharged unrecovered, and a further modification must be made on account of a considerable number of the readmissions referring to a comparatively small number of patients, some patients being readmitted many times during a period of twelve years." New Statistical Tables. — But perhaps the occur- rence of greatest importance in this direction, in the THE CURABILITY OF INSANITY. 153 course of the year just closed, is tlie adoption by the Massachusetts State Board of Health, Lunacy, and Charity, of a set of tables for the more perspicuous and more accurate presentation of the numerical rec- ords of the medical history of the hospitals and asylums for the insane which are the property of the State. This is a striking indication of practical progress ; and, whether this new system of tabulation be perfect or not, it is evidently a great improvement over that which has hitherto prevailed in this country. If it have defects, time will exjDOse them, and furnish the opportunity for correction. These tables have been used in the preparation of the annual report of the Northampton Lunatic Hospital for the ofiicial year 1879-80, with only one regret on the j)art of the writer. That regret has its origin in the fact that this reformation comes from what are familiarly termed outsiders. It ought to have come from the medical profession, and not that alone, but from the specialty of psychiatry, for the use of which the tables were designed. Recovered vei^sus Cured. — The following extract was written nearly twenty years ago, by a physician not now in the specialty, but who, at that time, was at the head of one of the largest institutions for the insane in America. It is an exposition of his reasons for using the term recovered in preference to cured, in his records of discharge. It is a spicy argument, and reveals the fact that it is no new thing for a physician engaged in the specialty to have comparatively little confidence in many of the recoveries announced in his reports : "We discharge only recovered (cured, if you will) 11 154 THE CURABILITY OF INSANITY. patients. I imagine their condition is exactly that of the cases which others call ' cured.'' I have a sort of awkward compunction in the matter; and, in writing off a patient in the column headed ' Result,' I have felt my pen stiff when marshalling the five letters of the word ' c-u-r-e-d.' " Topsy said she growed, and was never made by any one. One of my patients once told me the devil growed, for God was too good and wise to make such a rascal. My patients recover. I think ' recover' is a neuter, or intransitive verb, meaning to grow well, or perhaps, oftener, only to grow better ; therefore it meets my requirements of conscience better than the word ' cured,' which, being capable of a passive conjugation, insinuates that an intelligent agent has effected the change. And, further, these cured lunatics have such a mischievous trick of going mad again, some sooner, some later, and some oftener than others, — though some not at all, — that one feels a little timid to offer to the undiscriminating a word which they regard in a more unconditional signification than our specialty may do. " If I take to a watchmaker, for repair or adjustment, a watch which I know is radically bad, I do not exact from him establishment of perfect performance, but am content with restoration to its primary capability. If this is curing my watch — cured it is ; but I will be content to regard it as mere recovery (not, however, spontaneous) of its prior constitutional abnormality." Instructive Statistics. — I have received some in- formation in regard to one hundred and eighteen cases of insanity which have been treated in American hos- pitals, and the statistics of which have been published. THE CURABILITY OF INSANITY. 155 in tlie usual manner, in the annual reports of those in- stitutions. Singularly enough, all the patients were females. They are here presented in a group, for a purpose which will be perceived by any person who carefully reads the whole of this article. If Dr. Todd's well-known group of twenty-three cases at the Hartford E-etreat, and Dr. Gait's group of thir- teen cases at Williamsburg, Virginia, were sufficient in number to justify the inferences in regard to curability which were drawn from them, and which were largely influential in establishing a prevailing belief, then may we safely be permitted to derive some inferences from this group, which is more than three times as numerous as both of them. Age on Admission in 118 cases of Insanity in Females. AGE. From 26 to 30 years, inclusive 31 to 35 a (( 36 to 40 it (( 41 to 45 a a 46 to 50 a a 51 to b^ a a 5Q to 60 a a 61 to 65 a a 66 to 70 a a 71 to 75 a a Unknown • • • Total CASES, 1 2 2 3 17 13 30 7 25 11 7 118 Inferences. — Insanity in females under forty-five years of age is very rare, but it prevails to its greatest 156 THE CURABILITY OF INSANITY. extent among those who are from forty-five to sixty years old. It is also very frequent between the ages of sixty-five and seventy-five years. Age at First Admission. AGE. From 26 to 30 years . 41 to 45 " . 46 to 50 "... Total . CASES. 23 59 36 118 Inferences. — Of the three quinquennial periods in which all first admissions of insane females into hos- pitals take place, the period from forty-one to forty- five years of age, inclusive, furnishes the largest num- ber. They are less frequent, though still numerous, from forty-six to fifty years, and least frequent from twenty-six to thirty years. Marital Relations. — It is a remarkable fact that, in all of these one hundred and eighteen cases, the patients were married. Inferences. — Marriage is, in females, a most prolific cause of insanity. Mental disorders are apparently un- known among unmarried women. Occupation, or Industrial Relations. CASES Manufacturer's wife . . 59 Farmer's wife . . . . 36 Housekeeper . 22 Seamstress .... 1 Total . . 118 THE CURABILITY OF INSANITY. 157 Inferences. — Of all females, the wives of manufac- turers are the most prone to become insane. The wives of farmers are likewise greatly liable to the disease, and housekeepers suffer largely from the malign influence. Seamstresses have been known to become insane, but very rarely. In all other positions in society it would appear that females are exempt from mental? disease. Results of Treatment. CASES Recovered . . 102 Much improved . 1 Improved 5 Result not recorded 7 Unknown 2 Died . , . . 1 Total . 118 Inferences. — Insanity in females is one of the most curable of all diseases. Of 118 patients treated in the hospitals, 102 went forth " clothed and in their right mind," to bless their families, to make happy homes, and to become producers instead of consumers. This is equal to 86.44 per cent. Deaths among insane females are as rare as recoveries are frequent. Of the 118 patients above mentioned, only one died. This is only .84 of one per cent, of the cases treated. In what other disease of any severity is the mortality so small ? Explanation of the Foregoing Statistics. — On the assumption that my information is correct, and I have no reason to doubt either its authenticity or its 158 THE CURABILITY OF INSAITITY. accuracy, the foregoing tabulated figures are a true rep- resentation, so far as they go, of the history, in relation to insanity, of three persoj^s, all of them married women. The three women were admitted to hospitals a total of 118 times, and discharged as "recovered" (or under some recorded word or words which signify re- covery) 102 times. Having contributed the 102 re- coveries to the published statistics of insanity, one of them died, insane, in a hospital ; another died, insane, at home ; and the third and last, at the age of about seventy-five years, has entered an almshouse, there to spend the remainder of her days. In the future, as for many years in the past, so long as she lives, she will doubtless have from one to two attacks of insanity annually ; and the probability is great that she will eventually die insane. STUDY SIXTTM. (WRITTEN IN 1881.) The arguments already advanced in proof of the allegation that mental disorders are far less susceptible of cure than has generally heretofore been believed, ought to be, as to a great extent they have been, suffi- cient for their purpose. There is little necessity of additional evidence, either cumulative or other. Not only is the truth of the seven propositions derived as "conclusions" from my discussion of the subject five years ago becoming more and more widely recognized and acknowledged, both by the medical profession and by interested laymen, but an increasing number of the superintendents of hospitals and asylums so explain their statistics of recoveries as to give further proofs of that truth. In his report for 1880 of the Lancaster (England) County Lunatic Asylum, Dr. David M. Cassidy records 159 patients as discharged recovered in the course of the year. In 88 of them the recoveries were from a first attack, while 66 were patients who had previously recovered from earlier attacks. " Such recoveries," he writes, " as those in the latter category, must of course be taken for what they are worth. They are, in fact, relapsing cases, and nearly all will probably become again, more or less frequently, 159 160 THE CURABILITY OF INSANITY. asylum inmates. Nor should it be concealed that even among the eighty-eight primary recoveries many will probably relapse, and some will die insane. This sug- gests forcibly the consideration that the care and allevi- ation of the condition of the general body of the insane is at least as important a function of asylums as is the so-called ' cure' of a small percentage of cases, few of whom remain permanently sane. It also suggests the futility of making artificial distinctions between the curable and the incurable insane." Dr. G. Mackenzie Bacon, of the Cambridgeshire, Isle of Ely, and Borough of Cambridge Pauper Lunatic Asylum, in the report of that institution for 1880, after announcing his intention to " tabulate all the readrais- sions" of that institution from the time of its opening, proceeds as follows : " I feel it is only by such a method that we can arrive at the knowledge of what cases are really cured, and that it is important that asylum superintendents should know how many patients recover, in the sense of being restored to health for at least a considerable period, and not merely how soo7i a recovered 'patient returns to the same asylum, to again go through the farce of a recov- ery, and be readmitted perhaps in a week or a months Results, in 1879-80, at the Massachusetts State Hospitals. — The adoption, last year, by all the State hospitals for the insane in Massachusetts, of the new series of statistical tables prepared by the Board of Health, Lunacy, and Charity, has given us an advantage never before enjoyed. It has enabled us to show very nearly, if not positively, just what was done by those institu- tions, in the course of the official year 1879-80, towards THE CURABILITY OF INSANITY. 161 the restoration of the insane and the diminution of their number within the Commonwealth. At the four State hospitals, at Worcester, Taunton, Northampton, and Danvers, in the course of the year ending with September 30, 1880, the number of persons admitted was 1092, — persons, or individuals, be it un- derstood, because it not infrequently hapjDcns that one and the same person is admitted more than once in the course of a year. Of this number of persons, together with those who were in the said hospitals at the beginning of the year, the number of persons discharged recovered was 283. This makes the recoveries, calculated on the admissions — the method which ajDproximates most nearly the truth — equal to 25.91 per cent., or a small fraction more than one-fourth of the whole. Such, then, are the results for one year at our cura- tive State establishments. I have here stated them in the way that similar results have always, prior to the year 1880, been re2:)orted at the institutions for the insane throughout the United States. Even as so re- 23orted, giving to them all the advantage derived from a broad, general statement, with no examination into the detail of modifying facts and conditions, they yield no evidence of a great degree of curability of the insane. The curable tliree- fourths of former faith dwindles very nearly to one-fourth in absolute practice. The hospital at Danvers, the newest of the four in- stitutions mentioned, and situated nearest the populous centres of the State, received nearly all the recent cases from Boston during the past year. It probably also received all which were committed from Lynn, Salem, Lowell, and Lawrence. But as that hospital has been 162 THE CUEABILITY OF IISTSAlSriTY. only a short time in operation, I disregard it in the ex- position now about to be made, and take the three other hospitals, which have been in operation different periods, varying from twenty-three to forty-eight years. Those three older hospitals, at Worcester, Taunton, and Northampton, admitted during the official year 1879-80, 521 persons. They discharged recovered 118 persons, making a percentage of recoveries of 22.64, a noteworthy fraction less than one-fourth of the number admitted. But let us look a little farther. The three hosj)itals discharged 118 persons recovered; but they admitted 55 persons whom they had previously discharged re- covered. Consequently the actual gain, in the course of the year, of recovered persons in the community, was only 118 minus 55, which is 63. This is only 12.09 per cent., or less than one-eighth of the number of per- sons admitted. It is an average of 21 gained recoveries at each of three large hospitals, the average number of the patients of which was, for the year, equal to 503 for each. A fact yet unmentioned gives, at first view, a still more discouraging aspect to the case. The 55 persons readmitted after previous recovery had been discharged recovered, not alone once each, making 55 recoveries, but a total of 115 times. The public had been told, in the reports, of 115 recoveries of those 55 persons. Hence, if recoveries, and not persons, be considered, the three hospitals issued 118 ; but they took back 115 which had been previously issued, leaving in the gen- eral population a gain of only three, or an average of one for each hospital. THE CURABILITY OF INSAIS'ITY. 163 It is not improbable, however, that the excess of recoveries (1 1 5) over that of persons (55) readmitted, was counterbalanced by a similar excess of recoveries over that oi persons (118) discharged. For example, if one of the 5b persons readmitted had previously been dis- charged recovered five times, there may have been, among the 118 discharged recovered, one who had previously been discharged recovered an equal number of times. The statistics just given in aggregate for the three institutions were specifically, for each one of them, as follows : At the Worcester Hospital, the oldest of the three, although its present building is the newest, the number of persons admitted was 222. The number discharged recovered was 41, which is 18.46 per cent., or less than one-fifth of the admissions. But among the admissions were 25 persons whom it had previously discharged re- covered. Hence the actual gain of recovered persons outside of the hospital was only (41 minus 25) 16, or 7.2 per cent, of the number admitted. The 25 persons readmitted had been discharged re- covered a total of 58 times. At the Taunton Hospital, 184 persons were admitted, and 49 discharged recovered, a percentage of 26.62. Of those admitted, 19 had previously been discharged re- covered, so that the gain of recovered persons in the general population was only (49 minus 19) 30, or 16.3 per cent, of the admissions. The 19 persons readmitted had been discharged re- covered 35 times. At the Northampton Hospital, the number admitted was 115. The number discharged recovered was 28, 164 THE CURABILITY OF INSANITY. equal to 25.22 per cent. But of the persons admitted there were 11 who had previously been discharged re- covered. The gain of recovered persons in the com- munity was, therefore, only (28 minus 11) 17, or 14.78 per cent, of the number admitted. The 11 persons readmitted had been discharged re- covered a total of 22 times. It is believed that, from this exposition, it will be apparent that the method still almost universally prev- alent of reporting recoveries is, except in a technical or medical sense, very fallacious and deceptive ; and that, until some other method, similar to the new one in Massachusetts, be adopted, those statistics will be of but little value in the study of the problems of social science. At the Danvers Hospital, the number of persons admitted in the official year was 571. The number discharged recovered was 165, or 28.89 per cent. The proportion of recent cases received at that insti- tution was unquestionably, and for obvious reasons, larger than at either of the other three. That hospital had been in operation less than eighteen months at the beginning of the official year in question ; hence it could not be expected that, among the persons admitted, there should be many who had previously been discharged from it recovered. And yet there were some such readmissions — the report does not state how many ; but it was of so many persons that their total of recoveries was 18. A Glance at Great Britain. — Having shown the results at the State hospitals of Massachusetts, perhaps it may be permitted to extend our observation to some THE CURABILITY OF INSANITY. 165 of the similar institutions abroad, for the purpose of further illustrating the subject, as well as showing the advantages of our recently adopted method of reporting recoveries. At the British asylums, the method of reporting the statistics has always been essentially the same as it is in the United States. We, indeed, followed their ex- ample. But it has heretofore been my impression that the proportion of patients readmitted, after having been discharged recovered, is much smaller there than in this country. I have supposed that the British patients re- main longer in the hospitals than do the American, and that thus their recoveries are so confirmed that relapses, or subsequent attacks, are comparatively infrequent. From information recently received, I infer that, at least to a certain extent, I was mistaken, and that there is no very great difference in these respects be- tween the two countries. Dr. Clouston, of the Royal Edinburgh (Morningside) Asylum, in his report for 1880, has introduced tables by which the same light is thrown upon his statistics of recoveries as upon those of the Massachusetts insti- tutions by the new and recently adopted method of re- porting, with the exception that he does not clearly discriminate between cases (or 'patients) and persons. The admissions at Morningside, in 1880, were 347. Of these patients, the number suffering from the First attack of the disease was . . 231 Second attack Third attack Had had several attacks Congenital . 58 24 26 166 THE CURABILITY OF INSANITY. Hence it appears that, of the 347, no less than 108 (58 plus 24 plus 26), or nearly one-third of the whole, were admitted after recovery, either at Morningside or some other place, from one or more former attacks. The number of patients discharged, recovered, was 165. Of these, there were who Recovered for the first time in 1880 . 97 Had recovered in former years . . 63 Recovered more than once in 1880 . 5 Total 165 At the close of the year no less than nine of these had already been brought back to the asylum, and still remained there or had been removed unrecovered. No less than forty per cent., or four in every ten of the recoveries, were of persons who had had previous attacks from which they had recovered. The movement of the population at the Morningside Asylum is rapid. Many of the patients apparently re- main in the institution but a comparatively short time. For these reasons it is believed that the proportion of patients returning to it, after having been discharged recovered, is larger than at most of the British Asy- lums. In his report for 1880 of the Derbyshire (England) County Lunatic Asylum, Dr. J. Murray Lindsay states that in twenty per cent, of the admissions " there had been previous attacks of insanity." At the Richmond District Asylum, Dublin, Ireland, in 1880, the admis- sions were 420, of which Qb, or 15.47 per cent., were "relapsed cases." The number discharged recovered THE CURABILITY OF INSANITY. 167 was 167 ; but the gain of recovered persons in the gen- eral population was only 102 (167 minus 65). The British Medico-Psychological Association. — The most striking evidence of progressive thought relative to the general subject under consideration, is the fact that, at the annual meeting of the British Med- ico-Psychological Association, which was held in Lon- don in August last, the statistical committee of that society recommended for adoption some new tables, as well as alterations in some of those already in use, so modifying the series, as a whole, that the statistics of the Asylums can be reported with essentially the same detail, and the same persj)icuity in regard to recoveries, as is found in the new tables of the institutions in Mas- sachusetts. After a brief discussion, it was decided to postpone for one year the question of their adoption, for the pur- pose of giving the members an opportunity to study them, and to discuss their merits at the quarterly meet- ings. But there can hardly be a doubt as to the result. The proposed alterations will be adopted. In the pres- ent state of things — when, in consequence of the exist- ence of various organizations for the promotion of the objects of social science, the call, outside of the profes- sion, for information in regard to insanity is tenfold greater than it was forty years ago — the members of the British Association cannot afford to refuse to display their statistics in such manner as will render them val- uable to the members of those organizations. The present technical truthfulness of those statistics must be expanded into an absolute truthfulness, in regard to the relation between the disease and individuals, or the 168 THE CURABILITY OF INSANITY. most important part of the statistics themselves will soon become entirely, as they even now are essentially, valueless. Dr. Clouston is not going to recede from the position gained by the step in advance taken at the time of making the report just passed under review, — a position in which he could show not alone what his institution had accomplished during the year in relation to disease, but also to what extent its beneficial influence had affected his fellow-men. There are many others among his colleagues in the specialty in England and Scotland, who are even now ready to follow his exam- ple. The rest will doubtless mostly be ready at the expiration of the appointed year. Let them remember that, no less than forty years ago, a reformation in the statistics of insanity was called for by an Englishman whose keen and comprehensive intellect and whose soundness of judgment were second to those of no one of his countrymen who have written upon the subject. I allude to the late Samuel Tuke. In the thoughtful and excellent article used as an introduction to his translation of Dr. Maximilian Jacobi's treatise on the construction and management of institutions for the insane, he wrote as follows : " The whole subject of the mode of reporting the re- sults of our institutions for the insane calls loudly for attention, if we would arrive at any useful statistical comparisons as to the efiect of treatment and other cir- cumstances on the health of the patients, and in regard to the cure of this greatest of human maladies. The subject would not be unworthy of a special consultation among the professional men who are devoted to this de- partment of the medical art." THE CUEABILITY OF INSANITY. 169 Is it not apparent, from the very wording of this ex- tract, that its author had in view the specific changes — perhaps with others — which it is intended to accomplish by the adoption of the proposition now before the Medico-Psychological Association? Shall his sugges- tions be permitted to lie under the dust and ashes of a half-century before they are carried into effect ? Old but Valuable Gekman Statistics. — At the Siegburg Asylum, in Rhenish Prussia, an institution which at that time was under the superintendence of Dr. Maximilian Jacobi, the statistics of recoveries from January 1, 1825, to December 31, 1845, a period of twenty-one years, were as follows : Whole number recovered .... Living at the end of the period, and have had no relapse . . . . . Eelapsed, and recovered again at the Asy- lum ....... Eelapsed and not yet cured Relapsed and become incurable . . , Relapsed and died insane .... Died without a relapse .... Not heard from ...... The number of patients admitted in the course of the period is not given, and consequently the percentage of recoveries cannot be obtained. The statistics are valu- able chiefly for the purpose of ascertaining to what ex- tent the recoveries were permanent. At the time of the close of the twenty-one years, 259 of the 661 persons had " relapsed," or, as it is generally stated in this country, had had a second attack. This is equivalent to 39.1 per cent., or a slight fraction less 12 Men. Women. Total. 377 284 661 169 153 322 79 48 127 5 6 11 34 30 64 39 18 57 43 25 68 8 4 12 170 THE CURABILITY OF INSANITY. than two-fifths of the whole. But these are not final results. Within the ten years next following the close of the period the number of relapses would be large, especially among the patients who recovered in the last half of the period. If about ^^^o-fifths of the whole re- lapsed within the period, it appears perhaps more than probable that one-fifth (or half as many more) would relapse afterwards. Supposing this estimate to be ac- curate, the whole number of persons relapsed would be equal to three-fifths of the whole number of persons re- covered. This corresponds with Dr. Thurnam's well- known formula. In regard to the proportion of the persons recovered who would ultimately die insane, it will be perceived that, at the close of the period, it was still too early to furnish the data for a very accurate estimate. Some- thing, however, in that direction may be done. Already the number who had relapsed and died insane was 57. The number who had relapsed and become incurable, and who would consequently die insane, was 64. This gives a total of 121, or a little less than o?ie-fifth of the whole, whose deaths, while insane, were assured. Ac- cording to the above-mentioned formula, ^^^'o-fifths of the whole should die insane. Hence we must find a little over one-fifth, or in actual numbers 143, more who would die insane. These must be looked for, first, in the 322 who had not relapsed, but many of whom undoubtedly would relapse ; secondly, in the 127 who had relapsed and recovered again, and, judg- ing by what we know in regard to the liability to re- peated relapses, a very large proportion of whom would relapse again ; and, thirdly, in the 11 who had relapsed, THE CUEABTLITY OF INSANITY. 171 and were not yet cured. Of these 460 persons, it is not improbable, judging from wbat we have already learned from similar statistics, that as many as 143 would die insane. An Echo feom the Antipodes. — There are two lunatic asylums in South Australia. They are under the general supervision of a board of visitors, of which Dr. Alexander S. Paterson is chairman. The report for 1880 of this board, signed by the chairman as colonial surgeon, is before me. It deals with the sub- ject of recoveries with a commendable extent of detail, although it fails to discriminate between persons and cases, and to give the number of attacks and of recov- eries of those patients who have been readmitted after recovery. At the two asylums, Adelaide and Parkside, the ag- gregate number of admissions in 1880 was 223. The number of patients discharged recovered was 90, which is equal to 40.35 per cent. But of the patients ad- mitted, there were 35 who had previously been dis- charged recovered. The two institutions gave to the people 90 recoveries ; but they received back from the people 35 former recoveries. Therefore, the gain of recoveries among the people was (90 minus 35) only 55. This is 24.66 per cent, of the admissions. Five of the patients readmitted returned to the hos- j)ital within a month from the time at which they were discharged recovered. As might be expected, in a country so recently set- tled as South Australia, a large proportion of the recov- eries were from cases originating in intemperance. In no less than twenty-five cases of males, the form of the 172 THE CURABILITY OF INSANITY. disorder is called alcoholismus. The patients recovered in twenty-four of them. Eight of these were in the asylum less than a month each ; and the average time of treatment of the twenty-four was only one month and seven days. Athenian Success. — I now approach a section of this Study from the consideration of which I would gladly be released ; but, in the discussion of this sub- ject, it is proper that all fallacies should be exposed, and all sources of error pointed out. Neither fallacies nor errors are justifiable in the domain of science. Furthermore, I have been criticised for the assertion, in the pamphlet on the Curability of Insanity (Study First), that the medical officers of institutions for the insane are men " with like passions as other men," and therefore the introduction here of any evidence that sustains the truth of the assertion, is due to the spirit of even-handed justice. That the reader may enter more intelligently upon the matter, it may be remarked that, in Ohio, the superintendents of the State institutions for the insane are among those persons whose offices are the '^ spoils" which, according to the ethical code of partisanship, belong to the victors in politics. The mere statement of this fact is sufficient for the present purpose. Any attempt to present, in detail, the evils consequent upon such a state of things, would be irrelevant. In his report for 1880, of the State Asylum for the Insane at Athens, Ohio, Dr. H. C. Kutter, who had but recently been ajDpointed to the office of superintendent, mentions the discussion of the curability of insanity begun in the rej)orts of the Northampton Lunatic Hos- THE CUEABILITY OF INSANITY. 173 pital ; and, after stating that it has been taken up by- alienists all over the world, gives the following con- firmatory evidence of the truth of one of my "con- clusions" : "It has frequently happened that the same person has been discharged more than once during one year, and that each discharge has been reported as a separate cure. One person in Ohio is reported to have recov- ered seven times in one year, and while he figured in the annual report as seven ' recoveries,' was actually a patient in one of the wards at the time the report was made out." After some further remarks he proceeds as follows : " It has also been charged that these ' cures' are flexi- ble, and can be increased by the superintendent when- ever occasion arises to prove his superior fitness and qualifications as a specialist. This charge has been made repeatedly, and by many distinguished members of the profession, who have been disgusted with the idle talk about cures made by political superintendents, for the purpose of gaining cheap notoriety through the secular press. We have, perhaps, felt this in Ohio to a greater extent than in almost any other State in the Union. To show that these charges are not made with- out some foundation, and that some reason for the de- mand that is being pressed for a reform in our asylum statistics does exist, I will quote some interesting cures from the general register of this asylum. " During the two years previous to May 20, 1880, we find among the ' cures' the following remarkable cases. I quote from the male register, and presume the female register shows an equal proportion of remarkable cures : 174 THE CURABILITY OF INSANITY. CURES. " ' Duration of insanity over 50 years 1 20 6 18 3 15 3 12 3 6 16 Total over six years 32 Thus, in the course of two years, and from the men's department alone, thirty-two cases were discharged as recovered, in no one of which had the disease existed less than six years. In one it had existed fifty years ; and the average duration for the whole was more than twelve years. " Four of these," continues the doctor, " were cases of chronic dementia ; four were epileptic, with duration of insanity ranging from seven years to twenty-one years." No man who has had any considerable experience in a hospital for the insane can fail instantly to perceive the preposterous absurdity of such statistics as these. By a probably low estimate, there arc now in the public institutions of Massachusetts not less than fifteen hun- dred insane persons who might be set at liberty and reported as "cured," or "recovered," with as much propriety as were those thirty-two patients at the Athens Asylum. But by those thirty-two cases, to- gether, undoubtedly, with similar ones from the female department, the superintendent increased the propor- tion of his " cures" to 63.50 per cent. I am still of the opinion that " the medical ofiicers of institutions for the insane can claim no exemption THE CURABILITY OF INSANITY. 175 from the common weaknesses of human nature ;" that " they are men with like passions as other men," and that the degree of confidence which is to be placed in their statistics depends, to a large extent, upon the tem- perament and character of the person from whom they come. STUDY SKVENTH. (WRITTEN IN 1882.) One of the consequences of the publication of the articles on the Curability of Insanity, in the annual reports of the Northampton Lunatic Hospital, for the years 1876, 1877, and 1878, was the conviction, in the minds of the members of the State Board of Health, Lunacy, and Charity, of Massachusetts, that the long pursued method of reporting the statistics of the hos- pitals of the insane was so imperfect, in some respects, as to deceive rather than to enlighten the mind of the reader. Desiring to test, so far as possible, by new statistics, the main question in regard to curability, as well as to place the institutions of the State upon the right road toward the attainment of truth, that board, in 1879, procured the preparation of an almost entirely new series of tables, and recommended their adoption in place of those formerly used. The proposition was immedi- ately acceded to, not alone at the four State hospitals, but at the McLean Asylum and the City Asylum of Boston. The reports of two official years since that time have been published, and those of the third, which has just expired, will doubtless be in j^rint before the 1st of 176 THE CURABILITY OF INSAlSriTY. 177 January, 1883. We have already, then, in Massachu- setts, the results of a three years' experience under the new order of things which was introduced by the adop- tion of the tables mentioned. That period is sufficiently long to furnish material from which, as premises, con- clusions entitled to a very considerable degree of confi- dence may be drawn. Drs. Park, Brown, and Gold- smith, of the three hospitals at Worcester, Taunton, and Danvers respectively, have very courteously fur- nished me, in advance of publication, with the statistics of those institutions for the year recently elapsed. I propose to pass in review this new material from the four State establishments, and endeavor to ascertain its teachings. It should be stated that the figures of the statistics relate to persons and not to cases, the same person not having been counted twice within either year, whatever might have been the number of his admissions. It is possible that, in a few instances, the same person was admitted in more than one of the years ; but, if any such there were, the number is not sufficient materially to affect the results. 1— ADMISSIONS OF PERSONS IN THREE OFFICIAL YEARS. Hospitals. 1879-80. 1880-81. 1881-82. Totals. W orcester 222 184 115 571 237 267 120 488 304 237 119 507 763 688 354 1566 Taunton Northampton Dan V ers Totals 1092 1112 1167 3371 The principal value of this table is in its exhibition 178 THE CURABILITY OF INSANITY. of the progressive increase in the number of persons admitted to the hospitals. In the two years intervening between the first and the last report, that increase was seventy-five, — twenty in the first year and fifty-five in the second. This ratio of increase, if continued, would double the number of persons admitted as patients in 29.79, or, in round numbers, in thirty years. The population of the State is not increasing so rapidly as that, and consequently, so far as these figures are to be relied upon, the proportion of the insane committed to hospitals, as compared to the number of inhabitants of the State, is on the increase. At Worcester there was a regularly progressive in- crease in the numbers admitted. At Danvers and Taunton, where fluctuations in this res^DCct were the greatest, the admissions were largely governed by out- side influences, not natural but arbitrary. The patients from Boston were sent sometimes chiefly to one of them, sometimes to the other, as circumstances determined. 2.— ADMISSIONS AND RECOVEKIES OF PERSONS IN THREE YEARS. Hospitals. Persons Admitted. Persons discharged Recovered. Per cent, of Recoveries ou Admission. "Worcester Taunton Northampton 763 688 354 148 148 76 19.40— 21.51 + 21.47 Total of three hospitals Danvers 1805 1566 372 20.61 378 24.15 Whol e number 33 i 1 750 1 22.25 1 The hospital at Danvers has so recently been opened that it is exceptional, in some respects, as compared THE CUEABILITY OF INSAISTITY. 179 with the other three. The table is consequently so arranged that those three can be considered sepa- rately. The proclamation, " The best authorities assert that 75 to 90 per cent, of recent cases of insanity are curable," with which, or with something equivalent, each half-fledged tyro in mental diseases formerly soared into the regions of imaginative psychology, either in his annual report, as a recently installed su- perintendent, or in some article upon the subject, as a pamphleteer or a writer for periodicals, is familiar to those who have read the Northampton reports, even though they may not have met it in its original places. Like the " voice of the turtle," in Palestine, in the spring-time of seasons long gone by, that proclamation was, until within the last three or four years, often " heard in our land ;" but now, like the song of Childe Harold, it " hath ceased," or, at best, " has died into an echo," like his theme. Yet to him whose faith was challenged by its reiterated assertion, and whose hope was stimulated thereby into an expectation that all cases might soon be treated in their early stages, the table here presented cannot fail to be sadly and sorrow- fully interesting. It matters little what it is asserted can be done, so long as it is not done. To the philanthropist, the hu- manitarian, the political economist, the tax-payer, even the mere citizen, the important question is, not what is the proportion of the insane that has been alleged, on very flimsy grounds, to be susceptible of recovery, under certain given but often impossible circumstances, but what proportion of all who are taken to the hospitals 180 THE CURABILITY OF INSAI^ITY. do recover and return to their homes as useful members of society ? By the table just introduced, it is shown that in the course of the three official years ending with September 30, 1882, 3371 persons were admitted into the four State hospitals, and 750 persons were discharged from them as recovered. The recoveries were 22.25 per cent, of the admissions. Hence, not one-half, not even one- quarter, but only a fraction more than one-fifth as many persons recovered as were admitted. In the oldest three of the hospitals, the most recently erected of which has been in operation twenty-four years, the proportion of recoveries was still smaller, being 20.61 per cent., or almost precisely one-fifth, as compared with the persons admitted. It is not a little interesting to observe the very near approach to equality of these proportions in the oldest three of the hospitals. At Danvers, the ratio of recovery was larger. This is sufficiently explained by the fact that, at the begin- ning of the period of three years, that hospital had been in operation less than eighteen months. It was not full, and it was the resort for nearly all of the re- cent cases of insanity from the eleven cities, including Boston, from which it is easily accessible. For the purpose of further illustration, I here intro- duce a table showing the ratio of persons recovered to persons admitted, at each institution, in each of the three years, respectively. THE CURABILITY OF USTSANITY. 181 3.— PERCENTAGE OF PERSONS RECOVERED IN EACH YEAR. Hospital. 1879-80. 1880-81. 1881-82. For Three Years. 18.46 26.62 24.34 21.94 21.34 16.66 18.09 17.72 23.83 19.40— 21.51+ 21.47— Northanoptoii At the three hospitals 22.65 28.89 20.67 25.41 18.94 17.55 20.61— 24.15— 25.95 22.75 18.34 22.2.5— Perhaps the most notewortliy information derived from this table is, that at the hospitals, as a whole, there was a progressive diminution of the annual pro- portion of recoveries, from the beginning to the end of the period, as shown by the figures 25.95, 22.75, and 18.34. This regular but quite sufficiently rapid falling ofP in the proportion of persons recoverea, may be merely incidental and temjDorary, but nevertheless it is not en- couraging. The graded reduction of recoveries took place at the oldest three hospitals, but to a less extent. In the hospitals, as a whole, it was equal to 7.61 per cent, of the persons admitted ; in the oldest three hos- pitals it was only 8.71 per cent., or a fraction less than one-half as much. The greatest diminution, equal to 11.34 per cent, of the persons admitted, was at the Danvers Hospital. The cause of this is readily under- stood. As the institution became filled to crowding, the current of recent cases which had been flowing to it was, to a certain extent, diverted from its course, and directed toward the other hospitals. The largest percentage of annual recoveries at any of the oldest three hospitals, in the course of the period. 182 THE CURABILITY OF INSANITY. was 26.62, at Taunton, in 1879-80 ; and the smallest, 16.66, at Northampton, in 1880-81. It is a delicate matter thus to bring the several insti- tutions into the closest juxtaposition, for the purpose of a comparison of the results of their work. Were it not that I have great confidence in all and each of them, it would not be attempted. I regard these Massachusetts hospitals as among the best of their kind, not in the United States alone, but in the world ; and I most con- scientiously believe that they are now under a medical management so good, and so nearly equal, that any in- sane person who would recover at any one of them would likewise recover at either of the other three. We now approach a part of the statistics before us, perhaps the most important as well as the most inter- esting of all, in consequence of their bearing upon the question of the absolute curability of mental disorders. The extreme liability to relapse of a large proportion of the cases recovered from insanity, is now very generally known. In some instances the relapse and the recovery occur so frequently that some physicians maintain that there is no recovery ; but that the disease, during the apparently rational intervals of the patient, is merely in a state of suspense. But, in these cases, it is the almost universal practice at the hospitals, if they are discharged at the subsidence of each returning par- oxysm, to discharge them as recovered. As heretofore shown, the recoveries are thus sometimes largely in- creased beyond the number of persons. In view of these cases, I have often been reminded of the noto- rious old toper, who one day greatly surprised an acquaintance by telling him that he had "left off THE CURABILITY OF INSANITY. 183 drinking," and when the assertion was doubted, re- affirmed its truth, declaring, as undeniable proof of the fact, that he had " left off three times" that morning. The subjoined table shows the number of persons dis- charged recovered, and the number of persons readmit- ted, who had at some former time been discharged as recovered. 4.— EEADMISSION OF PERSONS FORMERLY DISCHARGED RECOVERED.* Hospital. Proportion of Readmitted to Discharged. Worcester 148 65 1 in 2.28 1 in 2.11 1 in 2.45 Taunton Northampton 148 70 76 .31 Totals of the three hospitals.... Danvers 872 378 166 66 1 in 2.24 1 in 5.72 Total of the four hospitals 750 232 1 in 3.23 In the return to their homes of 750 persons recovered from their insanity, the hos25itals accomplished a great good. This work of beneficence was, however, as is shown by the table, in one sense partially counterbal- anced by the readmission of 232 persons who had been previously discharged as recovered. The percentage of the readmissions on the discharges is 30.93. In other words, nearly one-third as many formerly recovered per- sons were taken back from the community as were given to it by the hospitals. At the oldest three hospitals the * An error which, in the original publication of this Study, occurred in this table, and which consequently affected the sta- tistics of the two succeeding ones, is here corrected. 184 THE CUEABILITY OF INSANITY. proportion was still larger, the number of formerly re- covered persons readmitted being to the number of re- covered persons discharged as 45 (44.62) to 100. At the Worcester Hospital, it was a fraction more than two-fifths; at the Taunton Hospital, nearly one-half; and at the Northampton Hospital, a trifle more than two-fifths. At the Danvers Hospital 378 persons were discharged as recovered, and only 66 formerly recovered persons readmitted. The proportion of the returned recovered to the discharged recovered, was as 1 to 5.72, or a little more than one-sixth. This, like the heretofore men- tioned exceptional results at that institution, is a con- sequence of its newness. As before mentioned, at .the beginning of the three years it had been in operation less than a year and a half, and hence there had not been time for a relapse of any of its recoveries other than in those persons whose disease recurs at short in- tervals. As will be seen by the table next to be intro- duced, the numbers of the readmitted recovered, in each of the three successive years, were 18, 17, and 31, re- spectively, nearly one-half of them being in the last year of the period. As the hospital grows older, this, as well as the other results in its medical history, will approximate more and more nearly those of the three other and more early established institutions. Before leaving this special topic, it should be re- marked that, although the Danvers Hospital read- mitted but comparatively few of the persons whom it had discharged as recovered, yet it is highly probable that it admitted a no inconsiderable number who had previously been discharged as recovered from the other THE CUEABILITY OF INSANITY. 185 three institutions. Tlie early rej)orts give no direct in- formation upon the subject, but within four and a half months from the day the hospital was opened, no less than forty-three patients suffering from a second attack were received. It is probable that the larger jDart of these had recovered from the first attack at other in- stitutions. The same may be said of the seventy-one patients with second attack admitted in the official year 1878-79, which began at the close of that period of four and a half months. Of these one hundred and fourteen patients, who knows how many had recovered once each, at either Worcester, Taunton, or jN'orthampton ? The number can be ascertained only by an examination of records. In the first two years of the three years' period to which these statistics refer, the Danvers Hospital ad- mitted one hundred and one patients who had been inmates of the other three hospitals mentioned, but we are not informed of the condition, in regard to recovery, in which they had been discharged from those hospitals. 5.— ANNUAL KEADMISSIONS OF PERSONS FORMERLY DISCHARGED RECOVERED. Hospitals. 1879-80. 1880-81. 1881-82. Totals. ^Vorcester 25 19 11 17 29 10 23 22 10 65 70 31 Taunton Northampton Total of three hospitals Danvers 55 18 56 17 55 31 166 66 Total of the four hospitals 73 73 86 232 Some of the most important information imparted 13 186 THE CURABILITY OF INSANITY. by this table has already been mentioned. By an ex- amination of the figures in detail, it would appear that the number of formerly recovered persons annually re- admitted is accidental, or incidental. It follows no law. There is neither a regularly progressive increase nor a regularly progressive decrease. The whole number ad- mitted in the first year is smaller by thirteen than that of the last year ; but, at the oldest three hospitals, the number in the first year was the same as that in the last year. So much in regard to the persons who had previously been discharged recovered, but who had returned to the hospitals. It will now be shown that some of those persons had been discharged recovered more than once. This will be done by giving the number of times that all of them (232) had been so discharged. 6.— RATIO OF EECOVEEIES TO PERSONS RECOVERED. Hospitals. KeadmiBBions of Persons formerly Dis- charged Kecov- ered. Number l of Times they ' Excess of had been Recoveries over Discharged ; Persons. Recovered. Average Re- coveries to each Person. 65 70 31 160 122 66 95 52 35 2.46 1.74 2.13— Taunton At the three hospitals.. 166 66 348 67 182 1 2.09+ 1.01 At the four hospitals... 232 415 183 1.79— Hence it will be perceived that the 232 recovered persons readmitted, had been discharged recovered 415 times. The excess of recoveries over persons is 183. At the oldest three hospitals the proportionate excess is THE CUEABILITY OF I^^SAXITY. 187 mucli larger. Their 166 formerly recovered j)ersons readmitted, liad been discharged recovered 348 times. The excess of recoveries over persons is 182. The number of recoveries is sixteen more than twice as great as that of persons. At the Worcester Hospital, much the oldest of the four establishments, Qb recovered persons readmitted had been discharged recovered 160 times. The excess of recoveries over persons is 95; and the number of recoveries nearly twice and a half as great as that of persons. At the Danvers Hospital the number of recoveries exceeds that of persons by only one. For reasons already given this result will be un- derstood. There is one supposable source of error in these sta- tistics of repeated recoveries, and that is the jDOssibility that a person who had been discharged recovered more than once, may have been so discharged in more than one of the three official years. If, for example, a per- son who had joreviously recovered three times were dis- charged recovered in the first year, making his fourth recovery, and being afterwards again admitted and dis- charged recovered, in either of the other two years, he would be reported twice in the period, once as having had three former recoveries, and again as having had four. This would make the number of his recoveries, as represented in the table, seven, whereas it had been but four. If the table contains such errors, they prob- ably do not increase the totals of repeated recoveries to a greater extent than they aje diminished by the admission of persons at Danvers who had j)reviously recovered at the other three hospitals. This rather minute and detailed analysis of the sta- 188 THE CUEABILITY OF INSANITY. tistics of recoveries at the Massachusetts State hospitals, is, from my point of view, more than justified by the circumstances under which it is made. The truth of the seven conclusions which were legitimate deductions from the data which, in 1876, I was able to glean from the results of observations and experience under an imperfect method of recording such statistics at the hospitals, was widely doubted. This doubt was no espe- cial cause for wonder, since, in some instances, those deductions differ very greatly from what, even in the minds of well-informed persons, had hitherto been re- garded as the truth. To a very considerable extent the doubt has been removed by the foregoing Studies. In Massachusetts a method of record and tabulation expressly designed for the purpose of bringing out, from the practical experience of its hospitals, the data which would prove or disprove the truth of those conclusions, has been in operation for some years. It was clearly proper that I should avail myself of the fruits of this crucial test, as I here have done. What are the re- sults ? The answer can best be made to appear by the reproduction in brief of several of the conclusions : Conclusion 1. — The reported recoveries are increased to an important extent by repeated recoveries of the same persons. This is proved by Table 6, where it is shown that at the oldest three hospitals 178 'persons were discharged recovered 348 times. Conclusion 2. — The recoveries of persons are much less numerous than the recoveries of patients or cases. This conclusion is, as a proposition, the converse of the first. Hence, it is proved by the converse of the THE CURABILITY OF INSANITY. 189 same statistics. At the oldest three hospitals the num- ber of recoveries of persons was but 178 ; the number of recoveries of patients, or cases, was 348, or very nearly twice as great as that of persons. Conclusion 3. — From the number of reported re- coveries of cases, or patients, it is generally impossible to ascertain the number of persons who recovered. This may also be proved by the same (6) table. Under the old method of reporting in this State, as well as elsewhere, the 348 recoveries at the three hos- pitals would have been published, without giving any clew to the number o^ persons in whom those recoveries took place. By the new method that number is given, and it is found, in this instance, to be 178. Conclusions 4 and 5 are, by their very nature, not susceptible of proof or disproof by these statistics. Conclusion 6. — The (formerly) assumed curability of insanity has been practically disproved by more ex- tensive experience. By cumulative evidence in Table 2, that disproof is corroborated and strongly fortified. At the four hospi- tals, 3371 persons were admitted, and only 750, or a trifle over one-fifth of them, were discharged recovered. This proportion — 22.25 per cent. — is much lower than was even dreamed of in 1876; and he who would then have ventured to assert that such could be the truth, would have been considered as either a Munchausen, an ignoramus, or a proper candidate for an asylum for im- beciles. It will be perceived that this reduction of the ratio of recoveries is in part due to the rejection of the dupli- cate and multiple recoveries of the same person, thus 190 THE CURABILITY OF INSANITY. giving to each person but one recovery. For all other than strictly technical or medical purposes, this is the information wanted. Conclusion 7. — The proportion of recoveries at the hospitals has been constantly diminishing, during a pe- riod of from twenty to fifty years. These statistics cannot prove anything anterior to 1876, when that conclusion was written. But by Table 3 it is demonstrated that, in the four Massachusetts hos- pitals, the diminution, since 1879, has continued, the progressive reduction being represented by the consecu- tive annual percentages — 25.95, 22.75, and 18.34. The proportion of recoveries in the year just elapsed is a little less than three-fourths as large as it was three years ago, in the official year 1879-80. Very clearly, if insanity is to be diminished, it must be by prevention and not by cure. With the foregoing exposition I might, perhaps, very appropriately close forever these published studies of the subject of the curability of insanity. If the argu- ments which have been used, and the illustrative proofs which have been adduced, in the course of a seven- years' discussion, have been insufficient to procure con- viction of the truth of the conclusions published in 1876, it is not probable that anything will have power to convince. It was once intimated that there were minds which would not " be persuaded though one rose from the dead." Others like them there may be at the present time. There is, however, one hitherto unused illustration furnished by the history of one of the American hospi- tals, that I cannot well forbear to adduce in the present THE CUEABILITY OF INSANITY. 191 connection. It corroborates the testimony of the expe- rience at the Massachusetts hospitals during the last three years, and emphasizes the force of it. The epidemic fever of opinion in favor of " good" — thereby meaning, as practically translated — "expensive" hospitals, which raged throughout the decennium from 1865 to 1875, or thereabouts, will be but too well re- membered. It left, for Massachusetts, its own elephan- tine monument upon Hathorne Hill, in such fashion that it is not likely soon to be forgotten by the people of the commonwealth, and, at the same time, similarly perpetuated its memory in other Stat^. Of all the ex- cessively costly curative institutions which were the products or outgrowths of that temporary craze, the Hudson River Hospital, at Poughkeepsie, New York, is, if I mistake not, the most remarkable for its costli- ness. Dan vers is but a pigmy as compared with it. It was intended to be the institution of institutions, des- tined, so long as it might exist, to stand as a practical, and therefore irrefutable, proof that lavish expenditure upon hospital buildings can cure insanity. That hospital was opened on the 20th of October, 1871, and its last published report covers the official year ending with the 30th of September, 1881. At the latter date it had been in operation ten years, minus twenty days. In the course of that decennium it admitted 1671 patients, and discharged as recovered 353. The per- centage of recoveries, as compared with the admissions, is 21.12, or a fraction more than one-fifth. In view of this result at the Hudson Kiver Hospital, one of the most prominent men engaged in the work 192 THE CURABILITY OF INSANITY. connected with the charities of the State of New York writes to me as follows : " If any additional evidence of the correctness of your conclusions in regard to the cura- bility of insanity is needed, it is furnished in the ten years' experience of this most expensive of institutions * established presumably for cure.' " The very near approach to identity in the results at Poughkeepsie and at the Massachusetts hospitals, may arrest the attention of the reader. The proportion of the recoveries was : At the Hudson Hiver Hospital 21.12 per cent. At the four Massachusetts hospitals . 22.25 " At the oldest three Massachusetts hospitals 20. 61 " But there is a difference in the computation of these ratios which operates pretty largely in favor of the Mas- sachusetts institutions. The statistics of Massachusetts relate only to persons ; those of Poughkeepsie to patients, or cases. The Hudson River Hospital gets the advan- tage of all the repeated recoveries of the same person, which, like all other institutions of the kind, it must have had ; whereas, at the Massachusetts hospitals, these were all rejected. Other appropriate topics, furnished by both the United States and Europe, might here be introduced, but I must pass them by, with two exceptions upon the other side of the Atlantic. In Dr. Clouston's interesting report for 1881 of the Morningside Asylum, at Edinburgh, the recoveries for the year are reported in a manner differing from that of the next preceding year, and by that difference the report becomes more lucid. The number of admissions, in the course of the year, was 339, of which 247 were THE CUEABILITY OF INSANITY. 193 for the first time, while 92 were readmissions. I here copy, in full, the table of recoveries : PEKSONS EECOVERED IN 1881. Males, j Females. Total. A Recovered for the first time 45 6 31 7 48 4 3 34 4 93 4 9 65 11 (a) Readmitted, and again discharged recovered (&) Readmitted, but not again dis- ch arged recovered B. Had made one or more recoveries in pre- vious vears (a) Readmitted, and again discharged recovered (6) Readmitted, but not again dis- charged recovered 76 76 82 86 158 162 " Number of cases of recovery The whole number of persons who recovered within the year was 158. Ninety-three of these recovered for the first time; but after their discharge as recovered, four of them were readmitted and again discharged re- covered. They made two recoveries each within the year. Nine more of them were readmitted, and, at the end of the year, still remained in the asylum. Although discharged recovered, and counted among the recoveries, they came back within the year. The remaining 65 of the persons who were discharged as recovered, did not recover for the first time ; but each one of them had recovered once or more in previous years. Of these Q6 who were discharged recovered within the year, 11 came back, and were still in the asylum at the expiration of the year. Summing the two classes, it appears that of the 158 194 THE CURABILITY OF INSANITY. persons discharged recovered within the year, 24 re- lapsed and were readmitted within the year. Four of them were discharged recovered a second time within the year, and 20 (9 plus 11) were still in the asylum at the close of the year. I have thus put the information in the table into the language of words, for the benefit of those who have no taste for the language of numerals. It is a lucid show- ing, so far as it goes, but it would have been more satis- factory if we had been told how many recoveries the 65 persons had made in previous years. A series of improved and reformatory tables, by which the defects in the method of reporting the sta- tistics of the institutions for the insane would be reme- died, was prepared by a committee and presented for adoption by the British Medico-Psychological Associa- tion in 1881. After due discussion, it was decided to postpone action upon the subject for one year. At the meeting of the Association in August of the current year, there was another discussion, which ended, at length, in the adoption, for one year, of the new tables. So far so good — and very good. A prudent caution in driving, even when one knows he is on the right road, is commendable. The superintendents of the British asylums will find that the new tables will increase their labors to a no in- considerable extent ; a fact of which no one perhaps is more conscious than they themselves. The work of pre- paring the statistics of the Northampton Hospital was increased, probably threefold, by the tables introduced three years ago. But the British superintendents have always put very much more work into their statistics THE CURABILITY OF IISTSAJSTITY. 195 than liave the superintendents of the institutions in this country ; and hence their labor will not be proportion- ately increased. But, for them and for us, it is the end that crowns the work, and all upon whom the burden is imposed must look for their reward in the greater revelation of truth, and the immensely enhanced value of their statistics. STUDY KIGHTH. (WRITTEN IN 1885.) It is proposed, in this paper, to show, by the collo- cation of statistics, the actual results of treatment at a large number of institutions, both foreign and domestic, bringing our knowledge of such general results to a later date than that contained in any former statistical essay. Recoveries at British Asylums. — ^The reports of many, if not most, of the British asylums contain a table, originally designed by Dr. Thurnam, in which the admissions, discharges, recoveries, and deaths of patients are classified according to the duration of the insanity. These classes are as follows : 1st. First attack, and within three months, on admis- sion. 2d. First attack, above three and within twelve months, on admission. 3d, Not first attack, and within twelve months, on admission. 4th. First attack or not, but of more than twelve months, on admission. 5th. Congenital and unknown. This is a well-conceived and useful table for its in- tended purpose ; and if, in practice, it be filled in with sufiicient care and discrimination, it cannot well fail to 196 THE CURABILITY OF INSANITY. 197 throw liglit upon the question of curability as affected by duration, or by the fact of first or subsequent attack. Nearly two years ago, I collated the statistics of this table in a series of the annual reports of twenty-three of the British asylums, so far as relates to all cases of less duration than twelve months at the time of admis- sion. For more than fifty years, all such cases have, in the United States, been called recent, in contradistinc- tion to those of remoter origin, which have been called chronic ; and my object in collecting the statistics was, to ascertain the degree of curability to which those asylums had attained in the treatment of what we call recent cases. Of each of twelve of the asylums, these statistics ex- tend over a series of six consecutive years, the last of which was, in some instances, 1882, and in the others, 1883. At three of the asylums they extend over five years ; at one, over four years ; and at seven, over three years. At each asylum the years are consecutive ; and at no one is the last of the series later than 1878, the majority being either 1880, 1881, or 1882. The results of these statistics may be briefly stated : First class (first attack, less than three months' dura- tion), the admissions were 8316; recoveries, 4051 ; per cent, of recoveries, 48.71. Second class (first attack, three to twelve months' duration), admissions 2613; recoveries, 764 ; percent, of recoveries, 29.24. Third class (not first attack, less than twelve months' duration), admissions, 4768 ; recoveries, 2640 ; per cent, of recoveries, 55.37. By uniting the first two classes, we have all cases of 198 THE CUEABILITY OF INSANITY. first attack and of less duration than one year. Of these, the admissions were 10,929; the recoveries, 4815; and the proportion of recoveries, 44.06 per cent. Of the third class the admissions were 4768 ; the re- coveries, 2640 ; and the proportion of recoveries, 55.37 per cent. Here we have another illustration of the fact that recovery takes place in a less proportion of cases of first attack than in cases subsequent to the first — as was demonstrated in Study Fifth. By a union of the three classes, all of which contain, exclusively, cases of less than twelve months in dura- tion, and are consequently here known as recent cases, we obtain the following results : Admissions, 15,697 ; re- coveries, 7455 ; proportion of recoveries, 47.49 per cent. Among this series of twenty-three asylums is the Retreat at York, the statistics of recoveries at which, from 1796 to 1819, have been quoted, ever since they were published, as one of the authorities for the eminent curability of mental disorders. It may not be unin- structive to bring into juxtaposition those statistics of three-fourths of a century ago, and those of the same institution for the five years from 1876 to 1880 inclusive. This is done in the following table : TABLE II.— PEE CENT. OF RECOVEKIES AT THE YOEK EE- TEEAT OF CASES OF LESS DUEATION THAN TWELVE MONTHS. Per cent. of Ist Class. Per cent. of 2d Class. Per cent. of 3d Class. Per cent. of Total. 1796 1819 85.10 50.00 55.55 42.86 61.76 36.11 68.25 43.30 1876 1880 Decrea'=e of per cent 35.10 12.69 25.65 24.95 THE CURABILITY OF INSANITY. 199 The diminution of the proportion of recoveries on the admissions is, for the first class, 35.10 per cent, of the admissions ; for the second class, 12.69 per cent. ; for the third class, 25.65 per cent. ; and for the whole, 24.95 per cent., or, in round numbers, one-fourth of the admissions. The proportion of diminution from the actual recov- eries of the first period, is, for the first class, 41.17 per cent., or a fraction more than two-fifths ; for the second class, 22.84 per cent., or a fraction more than one-fifth ; for the third class, 41.53 per cent., or a fraction over two-fifths ; and for the whole, 36.25 per cent. In other words, for each hundred of recoveries of what we call recent cases, three-fourths of a century ago, there are but sixty-four (63.75) recoveries now. Some months after the collection of the foregoing statistics, but before any use had been made of them. Dr. T. A. Chapman, of the Hereford Asylum, England, published a similar but much larger collection, in the Journal of Mental Science for July, 1884. It contains the statistics of " Forty-six English County and Bor- ough Asylums, and the Edinburgh and Glasgow Royal Asylums, for (in most instances) eleven years, 1872 to 1882 inclusive." Here is a collocation of the remarka- ble number of 93,443 cases of insanity, all of them classified as in the foregoing table. The whole number of recoveries was 35,468, or 37.95 per cent, of the ad- missions. But as the recoveries of recent cases are now alone under consideration, we will turn our attention es- pecially to them. The subjoined table (III.) shows the numbers, and the percentage, in each of the first three of Thurnam's classes. 200 THE CURABILITY OF INSANITY. TABLE III.— RECOVERIES OF CASES OF LESS DURATION THAN ONE YEAR. Classes. Admis- sions. Recoveries. Per cent, of Kecoveries. First attack ; less than three months' duration. II. First attack ; three to twelve months' duration. III. Not first attack ; less than twelve months' durati on 38,283 12,126 19,574 18,654 3,421 10,494 48.72 28.21 53.61 Totals and mean per cent 69,983 32,569 46.52 Dr. Chapman's table includes, apparently, twenty- eight asylums that are not in mine, and mine has five that are not in his. Of these five, two are in Scotland and three in England, the Retreat at York being one. In regarding these two collections of statistics, so much alike and yet so different, almost the first impres- sion received from them is the striking similarity of results. These are, indeed, so nearly identical as to justify one's faith in the sometime possibility of a close approximation to accuracy in this branch of vital sta- tistics. The difference in the proportion of recoveries, as indicated by the two, are, for the first class of cases, only .01 of one per cent. ; for the second class, 1.03 per cent. ; for the third class, 1.76 per cent. ; and for the total, .97 of one per cent. When Dr. Woodward, in 1833, took charge of the Worcester Hospital, he had before him, as exemplars, three well-known pioneers in the field of high percent- ages of recoveries. Dr. Burrows, in 1820, had reported THE CURABILITY OF INSANITY. 201 91.32 per cent, as the result of tlie treatment of 242 cases, of which 221 recovered. He also published the results, from 1797 to 1819, at the York Retreat, where, of 47 cases of less duration than three months, the recoveries were 40, or an equivalent of 85.10 per cent.* In 1827, Dr. Todd, at the Hartford Ketreat, reported that, of 23 recent cases admitted, 21 had recovered, a proportion of 91.3 per cent. In 1841, Dr. Woodward obtained his highest proportion of recoveries, 91.42 per cent., by the treatment of 70 cases, 64 of which recov- ered ; and in 1842, Dr. Gait, at the Williamsburg (Vir- ginia) Asylum, excelled all of his predecessors in the announcement that, of 13 recent cases under his care, 12 had recovered, a percentage of 92.3. Here we have five different, well-known medical au- thorities, each confirmatory and corroborative of the others, and all of which have, for an average of half a century, been regarded as a kind of oracular pro- claimers of the possible achievement of recovery in about 90 per cent, of recent cases. Yet, singularly enough, the whole of the five separate reputations were built, and the oracles established, upon the treatment of an aggregate of only 395 cases. On the other hand we have before us, in Dr. Chap- man's table, the results of treatment of a number of re- cent cases which lacks but seventeen to make it seventy thousand, and the recoveries are only 32,569, or 46.52 * The fact should not be overlooked that, if the word recent be used in its American signification, applying to all cases of less duration than one year, the proportion of recoveries at the Ee- treat was only 68.25 per cent., the admissions being 126, and the recoveries 86. 14 202 THE CURABILITY OF INSANITY. per cent. This ratio of curability is only eighty-six hundredths of one per cent, more than half as large as that which was claimed by Dr. Burrows, and only thirty-seven hundredths of one per cent, more than one-half as large as that of Dr. Gait. Even in the cases of first attack and of only three months' dura- tion, of which there were 38,283, the recoveries were but 18,654, or 48.72 per cent. In the light thrown upon the subject by this unparalleled collection of re- cent cases, what becomes of the once exceedingly fash- ionable assertion that " from seventy-five to ninety per cent, can be cured" ? E,ECOVERiES AT Thirty-nine (15+24) American Institutions. — Inasmuch as neither Thurnam's table, nor its equivalent in any other form, is used at the American institutions, it is impossible to group or to analyze the results at the latter on precisely the same basis in all respects. Nevertheless, upon looking over the American reports, I find that a large amount of matter may be brought together, illustrative of the proportion of the reported recoveries of recent cases. In the statistics of a majority of our hospitals, although in reference to admissions the duration of the insanity is given, and hence a distinction between recent and chronic cases rendered possible, yet no such discrimination is made in regard to patients discharged. The subjoined table contains the results, in regard to recovery, for a series of from three to six years, of fifteen American hospitals, in the reports of which the recoveries of cases of less than twelve months' duration are numerically given. The time during which each hospital, respec- THE CTJRABILITY OF INSANITY. 203 tively, furnislied these statistical results, is mentioned in the table. TABLE IV.— WHOLE NUMBER OF EECOVERIES, AND RE- COYERIES OF CASES OF LESS THAN TWELVE MONTHS' DURATION, AT FIFTEEN AMERICAN INSTITUTIONS. Hospitals. Elgin Concord Worcester Taunton Utica Harrisburg Dixmont Dayton Ossawatomie j 5 McLean 4 Northampton 4 Danvers Columbia, S.C.. Boston Winnebago Totals and mean per cent 68 = J. Ph 24.19 30.04 20.26 22.79 32.78 18.58 25.78 35.00 30.69 28.90 20.35 22.04 22.93 29.09 28.88 25.96 50.41 48.20 42.83 44.78 47.17 33.67 44.58 56.34 54.52 42.99 46.43 47.61 39.46 45.98 56.84 46.88 The aggregate of the admissions of all cases is 14,562 ; the aggregate recoveries, 3780; and the proportion of recoveries, 25.96 per cent. The largest proportion was 35 per cent, at Dayton ; and the smallest, 18.58 per cent., at Harrisburg. At five others it was less than 23 per cent., and at still five others less than 30 per per cent. ; while at three besides Dayton, it was over 30 per cent. The aggregate of admissions of recent cases is 8063 ; 204 THE CURABILITY OF INSANITY. that of recoveries of recent cases, 3112 ; and the propor- tion of recoveries of recent cases, 38.59 per cent. The largest proportion is 46.95 per cent., at Dayton ; and the smallest, 26.96 per cent., at Columbia, South Caro- lina. Of the thirteen others, the proportion at one was less than 30 per cent. ; at two, between 30 and 35 per cent. ; at five, between 35 and 40 per cent. ; and at five between 40 and 45 per cent. Finding that, in despite of the traditional " seventy- five to ninety per cent." of some of the fathers, not one of these hospitals discharged even forty-seven per cent, of recoveries of recent cases, while the mean or average of all of them was less than thirty-nine per cent., I studied the relation between the whole number of re- coveries and the number of admissions of recent cases. The whole number of recoveries is larger by 668 than the recoveries of recent cases ; and the number of ad- missions of recent cases is 6499 smaller than the whole number of admissions. Yet, strange as it may appear, the total of recoveries is only 46.88 per cent, of the ad- missions of recent cases ! The largest proportion, 56.84 per cent., is at Winnebago, and the least, 33.67 per cent., at Harrisburg. Of the remaining thirteen hospitals, the proportion is less than forty per cent, at one ; between forty and forty-five per cent, at four ; between forty-five and fifty per cent, at five ; between fifty and fifty-five per cent, at two ; and over fifty-five (56.34) per cent, at one. Thus, after aiding and assisting the recoveries of recent cases by a supplementary and a complimentary gift of the certainly not despicable number of 668 cases, we have been unable to swell them even to fifty per cent, of the admissions of recent cases ! THE CUKABILITY OF INSANITY. 205 We now come to the hospitals which give the dura- tion of the disease in the cases admitted, but give no such information in respect to the cases discharged. The following table includes the statistics, for a term of from three to six years each, of twenty-four institu- tions of this class. Of six of them the term was six years ; of eleven, five years ; of six, four years ; and at one, three years : TABLE V. -KECOVEKIES AT TWENTY-FOUE AMEEICAN INSTITUTIONS. Hospitals. Admissions. DiSCHAHGES. .a a o . a o •s a 3 o f- 1 "o H Per cent, of all Recoveries on Admissions of less than 12 Mos' Duration. Jacksonville, 111 Mt. Pleasant, Iowa... Fulton, Mo 6 6 6 6 6 6 I 5 5 5 5 5 5 5 5 5 4 4 4 4 4 4 3 1000 852 675 435 414 83 300 492 503 373 263 165 357 549 235 681 470 199 207 136 320 307 486 358 1,605 1,548 1,162 740 654 231 434 1,168 775 786 695 380 559 1,099 526 1,135 882 344 467 328 707 746 1,168 617 440 400 564 257 267 63 150 241 300 244 110 171 254 357 228 414 325 88 201 104 145 163 267 180 27.41 25.84 48.54 34.73 40.83 27.27 34.56 20.63 38.71 81.04 1583 45.00 45.44 32.48 43.35 36.48 36.85 25.58 43.04 31.71 20.51 21.85 22.86 29.17 44.00 46.95 83.56 59.08 64.49 75 90 50.00 48.98 59.64 65.42 41.83 104.00 71.15 65.03 97.02 60.79 69.15 44.22 97.10 76.47 45.31 53.09 54.94 50.28 St. Joseph, Mo Lincoln, Neb Jackson, La Hartford Retreat Middletown, Ct Middletown, N. Y... Trenton, N. J Danville, Pa Williamsburg, Va Richmond, Va U. S. Gov't Hospital. Jackson, Miss Cleveland, Ohio Longview, Ohio Brattleboro', Vt Staunton, Va "Weston, W. Va Pontiac, Mich Madison, Wis St. Peter, Minn Augusta, Me Totals and mean per cent 118 9860 18,756 , 5933 31.63 60.17 206 THE CUKABILITY OF INSANITY. The total of admissions is 18,756 ; the total of recov- eries, 5933 ; and the proportion of all recoveries on all admissions, 31.63 per cent. The largest per cent, of recoveries, 48.54, was at Fulton, Missouri, and the smallest, 15.83, at Danville, Pennsylvania. Of the remaining twenty-two institutions, the proportion was less than twenty-three per cent, at four ; from twenty- five to thirty per cent, at five ; from thirty to thirty- five per cent, at five ; from thirty-five to forty per cent, at three ; from forty to forty-five per cent, at three ; and from forty-five to forty-six per cent, at two. The whole number of recent cases admitted was 9860; the whole number of recoveries, as before stated, 5933 ; and the percentage of all recoveries upon the number of recent cases admitted, 60.17. Here, then, by setting aside and disregarding the 8896 cases of more than twelve months' duration, we have succeeded in raising the recoveries to a point above fifty per cent. By the union into one group, so far as they are sus- ceptible of such union, of the contents of these two tables, we obtain the following aggregate results. In thirty-nine American hospitals, during a period of from three to six years each, making an aggregate of one hundred and eighty-six years of hospital work, the number of patients admitted was 33,318 ; the number of patients discharged recovered, 9713 ; and the pro- portion of recoveries, as compared with admissions, 29.15 per cent. In the factors producing this result it will be observed that all the cases of duplicate, triplicate, and manifold recoveries of one and the same person are included, and yet the recoveries do not rise to thirty per cent. THE CURABILITY OF INSANITY. 207 The whole number of recent cases admitted was 17,923 ; the total of recoveries of both recent and chronic cases, as already mentioned, 9713 ; and the proportion of all recoveries, as compared with the ad- missions of recent cases, 54.19 per cent. But be it not forgotten that this result is obtained by the sacrifice, or annulment, of 15,395 admissions ; or, in other words, by calculating the proportion of recoveries upon a little more than one-half of the number of admissions. Recoveries at Twenty American Hospitals ; Third Term of Five Years. — It will be remem- bered that the First Study, which was written in 1876, contains a list of twenty institutions for the insane, so tabulated with their statistics as to show the proportion of recoveries at each of two quinquennial periods, — the first of those periods being the second quinquennium of the existence of those hospitals, respectively, and the last period being the quinquennium terminating in either 1876 or one of the two immediately preceding years. The longest time wholly intervening between those two quinquennia was forty-four years, at the McLean Asylum, Massachusetts ; the shortest, two years, at the Mendotal Hospital, Wisconsin ; and the mean or average time, eighteen and a half years. But the true mean time, as applied to the gathering of the statistics, — that is, the time from the middle of the first quinquennium to the middle of the last, — was five years longer, or twenty-three and a half years. The total of admissions in the first period was 14,516; the total of recoveries, 6689 ; and the proportion of re- coveries on admissions, 46.08 per cent. The admissions of the second period were 24,383 ; the recoveries, 8354 ; 208 THE CURABILITY OF INSAjSTITY. and tlie proportion of recoveries, 34.26 per cent., or a fall of 11.82 in that proportion. This diminution equals one-fourth, or, to be exact, 25.66 per cent., of the recov- eries of the first period. As eight years have elapsed since the close of the second period, it has appeared to me that some similar researches, at a still later date, might tend more fully to illustrate the subject of curability, and perhaps second- arily, or indirectly, the general character of the disease. Accordingly, I have collected the statistics of admis- sions and recoveries at the same twenty institutions dur- ing a third period of five years, the period terminating, at nineteen of them, in or with 1884, and at one, where the reports are biennial, in or with 1883. At two of the institutions, both of which report biennially, the duration of the period is six years. Those statistics, together with the results in each of the first two periods, are contained in the following table : THE CURABILITY OF INSANITY. 209 5.1^ ^ <-> -» p to p bo Id 'rfi. k) o bo o CO w I-- w bi ts5 o-i ">-' ^ oi 'rfi. o bi OlOiOOOiCOCOi— '_OtOi— 'COCni— '•-ai-'OiOiCO^JbCi S ? B 9.0 "-a QOCOCCOOGOOOOOCOOOCOOOQOOOOOOOCCGOCOOOCD GD^JOOCOGDCOCOCOCDQOCOOOOOCOCDOOGO^-IOOCO 050000000000000000COOO I I I I I 0*>-PCOI— '05tOCDQOOOOi*>-05COCOrfi.Cri050 IsSOOl— 'I— i(*».CnO5-JC0~Ils5tOC;>C0i— 'i-itOCntOO H- 'OiOO^JOJGOCOCSl— 'OOCOC/TCOCOi— 'I— 'COOO ts3COC5CO*>.ts5tOCOlNDCOO5ts0^"lOtv3i-i|-i|-'ls5 COi:O^JCOCOOi— 'tOCnCOH-OOscOCDCStOtsSCacO PCJTQO^JCDCCasOOl— 'OPOtO». CO 05 2 S*!^ 3gS. en O 00 • 00 ~» 00 I CO CTT CD I o p n ^ Kb g o 3 ® ^ © • o ® n B CO . 5' B « o -i g 210 THE CURABILITY OF INSANITY. The aggregate admissions, in the course of this third period, is 23,052 ; the aggregate recoveries, 6896 ; and the proportion of recoveries, 29.91 per cent, of the ad- missions, — a result which demonstrates that the re- ported recoveries have continued to diminish, during the last eight years, in very nearly the same annual ratio as they had diminished between the first and the second period. The following is a summary of the results of the whole investigation : Kecoveries in the first period, 46.08 per cent, of the admissions. Kecoveries in the second period, 34.26 per cent, of the admissions. Recoveries in the third period, 29.91 per cent, of the admissions. Decrease of recoveries from the first to the second period, 11.82 per cent, of the admissions. Decrease of recoveries from the second to the third period, 4.35 per cent, of the admissions. Total decrease of recoveries from the first to the third period, 16.17 per cent, of the admissions. The decrease of recoveries from the first to the second period is 25.66 per cent, of the recoveries of the first period. The decrease of recoveries from the second to the third period is 12.69 per cent, of the recoveries of the second period. The total decrease from the recoveries of the first period is equal to 35.09 per cent, of the recoveries of the first period. The numbers of the insane subjected to treatment THE CUEABILITY OF INSANITY. 211 being hypothetically the same at the three periods, then, for each hundred that recovered in the first period, only seventy-four (74.34) recovered in the second period, and only sixty-five (64.91) recover now. The proportion of recoveries between the last two periods, from 1879 to 1884, did not diminish at all of the twenty institutions. At three of them it increased. At the McLean Asylum this increase was 7.56 per cent, of the admissions; at the Newburg, Ohio, Hos- pital it was 8.24 per cent. ; and at the Mendota, Wisconsin, Hospital, 1.56 per cent. But notwithstand- ing this augmentation, the actual decrease from the proportion recovered in the first period, at those three institutions, is still 11.47, 8.36, and 6.40 per cent., re- spectively. The decrease from the second to the third period, and the total decrease from the first to the third period, at each of the seventeen other institutions, may be learned from the last two columns of the table. The decrease is more than one-half at the Worcester and the Flat- bush Hospital ; very nearly one-half at Brattleboro' and Taunton ; and more than one-third at Augusta, Concord, Hartford, Pennsylvania Hospital, Dixmont, Catonsville, Dayton, and Jacksonville. Statistics of One Yeae at Fifty-eight Amer- ican Institutions. — For the purpose of ascertaining the extent to which the results of one year of the cur- rent work at American institutions would enlighten us upon the subject of curability, I have collected and herewith present, in Table VII., the statistics of fifty- eight of them, taken, in fifty-one instances, from the reports for 1884. Of seven of the hospitals the reports 212 THE CURABILITY OF INSAJ^ITY. are biennial, and consequently contain the results for two years each. In four instances the report from which these results were taken ended in 1884 ; in one instance in 1883, and in two in 1882. I am well aware of the many influences, both favor- able and unfavorable, which may, and often do, modify the number of recoveries, as well as of deaths, in pub- lic institutions, and which necessarily render the results of any one year unreliable, as a test or measure of the work of a series of years, at any individual hospital. But at a large number of institutions, on any given year, these influences would probably very nearly bal- ance one another, and consequently the aggregate re- sults would fairly represent the mean, or average, of the same group of institutions for a much greater length of time. THE CUEABILITY OF INSANITY. 213 TABLE VII.— ONE TEAE AT EIFTY-EIGHT AMEEICAN INSTITUTIONS. Institution. State. Tear. Admitted. 1 BecoT- ered. Per cent. of Eecov- eries. Died. Per cent. of Deaths. Me N. H Vt 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 ]884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1882-84 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1884 1883-84 1882-83 1883 188.3-84 1883-84 1881-82 1881-82 1884 203 141 82 113 252 136 283 5.30 121 106 97 271 136 479 372t 275 175 210 203 128 189 201 a56 203 95 169 347 133 119 176 106 81 71 293 2.54 82 222 282 220 188 223 220 908 192 174 240 123 220 291 239 601 5.34 23;^ 595 299 364 316 500 59 18 23 34 53 25 85 96 34 46 37 72 55 47 89 80 62 37 51 23 28 37 92 36 29 77 79 55 97 74 26 26 31 72 66 42 67 164 87 60 96 56 329 62 17 56 38 67 48 58 148 120 38 143 55 175 110 130 29.06 12.77 28.05 30.09 21.03 18.38 30.04 18.11 28.10 43.40 38.14 26.57 40.44 9.81 23.92 29.09 29.71 17.62 25.12 17.97 14.81 18.41 25.84 17.73 30.53 45.56 22.77 41.35 81.51 42.05 24.53 32.10 43.66 24.57 25.98 51.22 30.18 58.16 39.55 31.91 43.05 25.45 36.23 32.29 9.77 23..33 30.89 30.4.5 16.49 24.27 24.63 22.47 16.31 24.03 18.39 48.08 34.81 26.00 101 24 29 17 57 25 65 101 32 13 18 80 27 101 56 43 64 57 40 36 69 29 96 46 30 45 67 36 61 39 11 14 9 143 41 21 62 59 37 37 &3 58 112 29 9 32 21 33 31 .30 115 98 34 82 43 113 49 90 49.75 17.02 .3.5.36 15.04 22.62 18.38 22.97 19.06 26.45 12.26 18.56 29.52 19.85 21.09 15.05 1.5.63 .36..57 27.14 19.70 28.12 36..50 14.42 26.96 22.66 31..57 26.62 19.30 27.06 .51.26 22.15 10..37 17.28 12.67 48.80 16.14 25.61 27.93 20.92 16.81 19.68 28.25 26.36 12..33 15.10 .5.17 1.3..33 17.07 1.5.00 10.65 12..S5 19.13 18.-3.5 14.59 13.78 14.38 .31.04 1.5..51 18.00 Mass Mass Mass Mass Mass Mass R. I Ct Butler Hartford Retreat... ct N. Y N. Y N. Y N. Y N.J N. J Pa Pa Pa Pa Pa Pa Md Flatbush Utica Buflfalo Penna. Hospital Md D. Va Va W. Va... N. C N. C N. C s. c Texas.... Ark Tenn.*... Ohio Ohio Ohio Ohio Ohio Ind Mich Mich Ill Morganton Little Rock Elgin Ill Ill Ill Wis Wis.* Iowa.*... Iowa Minn.*.. Minn.*.. Mo.* Mo.* Cal Mendota Oshkosh Mt. Plea.«aut Independence St. Peter Rochester Fulton St. Joseph Napa Totals and mean per cent 1 14,372 4007 27.88 2980 20.74 * Biennial. t 15 cases "found not insane" are deducted. 214 THE CURABILITY OF INSANITY. The aggregate of patients admitted at these fifty- eight institutions, in the course of the time specified, is 14,372 ; the aggregate of recoveries, 4007 ; and the proportion of recoveries, calculated upon the admissions, 27.88 per cent., or a trifle more than one-fourth. The least relative number of recoveries, 9.77 per cent., was at Kalamazoo; and the largest, 81.51 per cent., at Richmond. In the following schedule the hospitals are arranged in groups, according to the proportion of their recov- eries, each group differing five per cent, from the one above or below it. Below 10 per cent., Flatbush and Kalamazoo. From 10 to 15 per cent., Concord and Dixmont. From 15 to 20 per cent., Northampton, Danvers, Morristown, Harrisburg, Danville, Warren, Kan- kakee, Independence, and Eochester. From 20 to 25 per cent., Worcester, Utica, U. S. Government Hospital, Ealeigh, Columbia, S. C, Jacksonville, Mendota, Oshkosh, Mt. Pleasant, and St. Peter. From 25 to 30 per cent., Augusta, Brattleboro', Boston, Middle- town, Ct., Buffalo, Trenton, Pennsyl- vania Hospital, Norristown, Austin, Longview, and ISTapa. From 30 to 35 per cent., McLean, Taunton, Catonsville, Golds- boro', Nashville, Dayton, Pontiac, Elgin, Anna, and St. Joseph, From 35 to 40 per cent., Hartford Retreat, Newburg, and Indian- apolis. From 40 to 45 per cent., Butler, Bloomingdale, Staunton, Weston, Morganton, and Athens. From 45 to 50 per cent.. Mount Hope and Fulton. From 50 to 55 per cent., Little Eock. From 55 to 60 per cent., Columbus. Over 80 per cent., Eichmond. THE CTJKABILITY OF INSANITY. 215 If there be no mistake in the record from the Virginia Central Asylum, at Richmond, that institu- tion, so far as my knowledge extends, has exceeded every other of its kind, not in America alone but upon the whole surface of the earth, in the proportion of its recoveries. Forty years ago, it was doing well to report the recovery of eighty per cent, of recent cases. At the present time, it is rare that even sixty per cent, are so reported, and the average in the United States, as we have just seen, is below forty per cent. But here we are confronted with a proportion of 81.51 per cent, of recoveries of all the cases admitted I The moral to be derived herefrom appears to be, that, if any person yet unborn be blessed with the pre-natal power of foreordination of his own physical organization, and desires to recover in case he be afflicted with insanity, he should elect to be born a negro.* There is yet another useful moral to be derived from the case. At the Danvers Hospital, which, before it went into operation, had cost more than three thousand five hundred dollars for every patient for whom its accommodations were calculated, and more than two thousand five hundred dollars for each of the seven hundred patients who have been crowded into it, the per cent, of recoveries was 18.11. At the Richmond Hospital, which apparently could not have cost over one hundred dollars, and probably not more than fifty dollars per patient, the recoveries were equal to 81.51 per cent. The moral is so conspicuously obvious that it would be a work of supererogation to put it in print. * The Yirginia Central Asylum is for colored persons. 216 THE CURABILITY OF INSANITY. In Table VIII., the fifty-eight hospitals and statistics are grouped according to the States in which they are respectively situated. TABLE VIII.— STATE GROUPS, ONE YEAR. No. of Hospi- tals. Admis- sions. Maine New Hampshire Vermont Massachusetts Rhode Island Connecticut New York New Jersey Pennsylvania Maryland District of Columbia Virginia West Virginia North Carolina South Carolina Texas Arkansas Tennessee Ohio Michigan Indiana Illinois "Wisconsin Iowa Minnesota Missouri California Totals and mean per cent. 58 203 141 82 1,435 106 368 1,262 385 1,280 264 347 252 176 258 293 254 82 222 1,133 366 908 874 840 767 894 680 500 Kecov- eries. 59 18 23 327 46 109 271 89 267 106 79 152 74 83 72 66 42 67 463 79 329 209 206 158 198 285 130 14,372 4007 Per cent. of Kecov- eries. 29.06 12.77 28.05 22.79 43.40 29.62 21.47 23.12 20.80 40.15 22.77 60.31 42.05 32.17 24.57 25.98 51.22 30.18 40.86 21.58 36.23 23.91 24.52 20.60 22.14 41.91 26.00 27.88 101 24 29 297 13 98 227 121 316 75 67 97 39 34 143 41 21 62 254 38 112 117 145 132 125 162 90 2980 Per cent. of Deaths. 49.75 17.02 35.36 20.69 12.26 26.63 17.99 31.15 24.69 28.41 19.31 38.49 22.15 13.18 48.80 16.14 25.61 27.93 22.41 10.38 12.38 13.38 17.26 17.21 13.98 23.82 18.00 20.74 The proportion of recoveries was the smallest in New Hampshire, and that proportion increased in the other States in the following order : Pennsylvania, Iowa, New York, Michigan, Minnesota, District of Columbia, Massachusetts, New Jersey, Illinois, Wisconsin, South Carolina, Texas, California, Vermont, Maine, Connec- THE CURABILITY OF INSANITY. 217 ticut, Tennessee, North Carolina, Indiana, Maryland, Ohio, Missouri, West Virginia, Ehode Island, Arkan- sas, and Virginia. If the statistics of recoveries be arranged in accord- ance with the groups popularly called the Eastern, the Middle, the Southern, and the Western States, the re- sults are as follows: — and to them are appended the percentage of deaths, calculated, like the recoveries, upon the number of patients admitted. In the Eastern States the total of admissions was 2335 ; the total of recoveries, 582 ; and the proportion of recoveries, 24.92 per cent. The number of deaths was 562, and the proportion, 24.07 per cent. The num- ber of recoveries exceeded that of deaths by only 20. ' In the Middle States the number of admissions was 2927 ; the number of recoveries, 627 ; and the propor- tion of recoveries, 21.42 per cent. There were 664 deaths, equal to a percentage of 22.69. The deaths have a majority of 37 over the recoveries ; and the pro- portion of both recoveries and deaths is less than in the Eastern States. It has been suggested, in one of the criticisms of a psychological periodical, that the small ratio of recoveries in Massachusetts is a consequence of the published writings of the superintendent of one of the hospitals in that State. As, according to these sta- tistics, the proportion of recoveries is less in the Middle States than in Massachusetts, the proposition now is, — Whose published writings were the cause of itf In the Southern States 1844 patients were admitted ; and 632, or 34.27 per cent., recovered. The total of deaths was 496, or 26.90 per cent. The proportion of recoveries is nearly ten per cent, on the admissions in 15 218 THE CUE ABILITY OF INSANITY. excess of those of the Eastern States ; and that of deaths nearly three per cent. The proportion of recoveries is considerably increased by the statistics of the Richmond Asylum. If thoSe statistics be set aside, and the com- putation made upon the returns from the other South- ern institutions, the results are : Admissions, 1725 ; re- coveries, 535 ; per cent, of recoveries, 31.21. Deaths, 435; per cent, of deaths on admissions, 25.21. In the Western States the admissions were 7266 ; the recoveries, 2166 ; and the proportion of them, 29.81 per cent. Of deaths there were 1258, or a proportion of 17.31 per cent., which is more than five per cent, of the admissions less than in either of the other sections. Arranged in accordance with the increasing ratio of recoveries, that is, from lowest to highest, the sections stand as follows : Middle, Eastern, Western, Southern ; and in accordance with the decreasing ratio, from highest to lowest, of deaths, as follows : Southern, Eastern, Middle, Western. These results are derived from the work of but a single year, and hence are unreliable as an established formula. By the extension of the investigation over a sufficient series of years, something more surely indica- tive of a permanent truth might be obtained. When that shall have been done, speculation upon the causes of the differences will be more appropriate than it would be at the present time. Statistics of Pennsylvania Hospitals. — The table to which attention is now requested includes statistics of the seven hospitals in Pennsylvania, during a period of five years each, with the exception of that at Warren, which is of but four years. At all of them the period ended in, or with, the year 1884. THE CURABILITY OF INSAjSTITY. 219 TABLE IX.— PENNSYLVANIA HOSPITALS. Tears. Admit- ted. Eecov- eries. Per cent. of Kecov- eries. Died. Per cent. of Deaths. 1880-84 1880-84 1880-84 1880-84 1880-84 1880-84 1881-84 196 973 968 772 720 1458 847 58 328 216 121 114 275 92 29.59 3374 22.31 15.97 15.83 18.86 10.86 39 147 277 174 118 290 113 19.90 15.11 28.61 22.54 16.39 19.89 13.84 Pennsylvania Hospital.... Harrisburg Danville Totals and mean per cent. 5934 1204 20.29 1158 19.51 The whole number of cases admitted was 5934 ; the total of recoveries, 1204 ; and the proportion of re- coveries, 20.29 per cent. But Norristown and Warren are both new hospitals, and in their first years received many transfers from other institutions. Hence they are unfairly represented. We will therefore permit the sta- tistics of only the last two years at these institutions to enter into the computation, retaining, for the others, the full period of five years. Those statistics are as follows : Tears. Admit- ted. T, ' Per cent. ^fr ofRecov- «'«'^- 1 eries. 1 Died. Per cent. of Deatlis. Norristown 1883-84 1883-84 777 388 1 195 25.09 70 18.04 219 80 28.18 20.62 ^V^arren Totals and mean per cent. 4794 1102 22.98 1054 21.98 By a substitution of these figures for those contained in the next preceding table, it will be found that the whole number of admissions is 4794 ; the number of recoveries, 1102 ; and the proportion of recoveries, 22.98 per cent., or a gain of 2.69 percent, on the admissions, by the change. 220 THE CURABILITY OF INSANITY. At the four State hospitals of Massachusetts, the proportion of recoveries in the three fiscal years ending in 1882, and the statistics of which form the basis of a section of Study Seventh, was 22.25 per cent. This is .73 of one per cent, less than that of the Pennsylvania hospitals, according to these statistics. But this dif- ference is more than counterbalanced by the fact that the Massachusetts statistics relate to persons only, while those of Pennsylvania relate to cases. In the latter all duplicate, triplicate, and multiplicate recoveries are included, while in the former they are all rejected. By the first of the two tables the deaths were 1158, and their proportion on the admissions, 19.51 per cent. By the last table they were 1054, and their proportion, 21.98 per cent., or an increase of 2.47 per cent. This increase is a natural result, as deaths are generally comparatively few in the first two or three years of a hospital's operations. Testimony of the Danvers Hospital. — The ex- perience at the newest State institution in Massachusetts is both instructive and disappointingly interesting, in the light which it throws upon the curable, or rather the incurable, condition of a great mass of the insane of the present epoch in that State. The Danvers hospital was opened for the reception of patients on the 18th of May, 1878 ; and, during the last four or five years, it has been directed by the highest grade of medical ability. It is, emphatically, one of those establishments upon which a flood of money has been j)oured, for tlie purpose of creating a curative institution as nearly perfect as possible under the light of existing knowledge. If abundance of pecuniary THE CURABILITY OF INSANITY. 221 means in construction, together with what was believed to be the highest embodied ideal of architectural ar- rangements, could cure insanity more rapidly than a less costly and more simple structure, that hospital, most assuredly, was prepared for a demonstration of the proposition. It was evident, in its earliest years, that great efforts were made to arrive at such a demon- stration, and thus prove that the curative advantages of the institution were an adequate, or — since the value of reason restored is not to be measured by dollars and cents — more than adequate compensation for the excess of expenditure. The usual custom of a large transfer of chronic and incurable cases from older hospitals or asylums to the new one, was here omitted, and the supply of patients was derived chiefly from current commitments. By this means the proportion of recent cases was much higher than usual from the first ; and as Boston and several other large centres of population — wdiich usually furnish a larger ratio of recent cases than the rural districts — are within a comparatively short dis- tance from it, that proportion was raised still higher. The fiscal year of the State institutions terminated four and one-half months after the hospital was opened. During this period 305 patients were admitted ; and 26, or 8.82 per cent., discharged recovered. In the course of the next — 1878-79 — fiscal year, 653 were admitted ; and 115, or 17.61 per cent., discharged recovered. In 1879-80 the admissions were 581, and the discharge of recoveries 165, making the percentage of the latter 28.40. At this point the proportion of recoveries stopped upon its ascending scale, and took a retrograde direction. In 1880-81 the admissions were 497, the 222 THE CURABILITY OF INSANITY. recoveries discharged 124, and the percentage 24.95 ; in 1881-82, admissions 512, discharged recoveries 89, per- centage 17.38 ; in 1882-83, admissions 488, discharged recoveries 80, percentage 16.39 ; and in 1883-84, ad- missions 530, discharged recoveries 96, and the per- centage of the latter 18.11. The whole number of admissions, during the six years and four and one-half months, was 3566; and that of discharged recoveries 695, or an equivalent of 19.49 per cent. In the first three full fiscal years, the admissions were 1731, the discharged recoveries 404, and the percentage of the latter 23.34 ; and in the last three fiscal years, admissions 1530, discharged recov- eries 265, percentage of recoveries 17.32. In the first period of three years, the deaths were 240, or 13.86 per cent, of the admissions ; and in the last period 285, or 18.63 per cent, of the admissions. In the first period the deaths were 240, a percentage of 59.4 on the recov- eries ; and in the last period they exceeded the recoveries by 20, the deaths being to the recoveries as 57 to 53. The new formulae for statistics in Massachusetts give the ability still further to illustrate the character of the recoveries, — an ability rendered by the reports of no other State in the Union. In the course of the five fiscal years ending September 30, 1884, 554 patients, or cases, were discharged recovered from the Danvers hospital; but 115 persons, who had been discharged recovered a total of 121 times, had returned to it. Within the last three years, — which are included in the foregoing years, — the discharged recoveries were 265 ; but, during the same time, 80 persons, representing 86 of those recoveries, were readmitted. So far as the THE CURABILITY OF INSANITY. 223 community is concerned, these recoveries offset, or cancel, the same number of the discharged recoveries, and the added recoveries in the population, instead of being 265, are 265 minus 86, or 179, a diminution of about one-third, and only 11.70 per cent, on the number of admissions during that period. Readmitted Recoveries in Massachusetts. — I now desire to call attention to some points in the statistical history of recoveries at the State hospitals of Massachu- setts, during the two years since the original publication of Study Seventh. For this purpose a table is here in- troduced which shows, for the fiscal years 1882-83 and 1883-84 : 1st. The number of persons admitted who had pre- viously been discharged recovered ; 2d. The number of times they had previously recov- ered; 3d. The ratio of recoveries to persons ; and 4th. The number of persons discharged recovered during those two years, at each of the four hospitals aforesaid. table X.— two years at MASSACHUSETTS HOSPITALS. Hospitals. Admissions. DlSCHARQES. Persons Admit- ted who had previously been Discharged Ke- covered. No. of times they had Recovered. Ratio of Re- coveries to Persons. Persons Dis- charged Recovered. ^Vorcester 43 64 21 49 118 147 39 54 2.73 2.29 1.85 1.1 109 145 53 176 Taunton Northampton Dan vers Totals 177 358 2.02 483 224 THE CUKABILITY OF INSANITY. The number of persons admitted who had previoHsly been discharged recovered was 177 ; and they had been discharged recovered a total of 358 times. There were 181 more recoveries than persons. In other words, the number of recoveries was four more than twice as great as the number of persons. Each person had recovered, as a mean or average number, 2.02 times. Regarded, during the last two years, from a debt and credit point of view, those four institutions cancelled, by taking back from the general population, no less than 358 re- coveries for which they had been credited. During the same time they discharged recovered 483 persons, which is only 125 more than the recoveries (not persons) which they had taken back. Summary. — A brief resume of the most important results of the foregoing Studies, expressed in the per- centages of recoveries, may be found convenient for reference. 1. Cases of first attack ; duration less thaii three months. a. Earle's 8316 cases, at 23 British asylums. Ke- coveries 48.71 per cent. b. Chapman's 38,283 cases, at 46 British asylums. Recoveries 48.72 per cent. 2. Cases of first attach ; duration less than twelve months. a. Earle's 10,929 cases, at 23 British asylums. Re- coveries 44.06 per cent. b. Chapman's 50,409 cases, at 46 British asylums. Recoveries 43.79 per cent. THE CURABILITY OF INSANITY. 225 3. Not first attach ; duration less than twelve months. a. Earle's 4768 cases, at 23 British asylums. Ee- coveries 55.37 per cent. b. Chapman's 19,574 cases, at 46 British asykims. Becoveries 53.61 per cent. In neither of the three foregoing classes have we any American statistics, because our institutions, in the tab- ulation of their cases, make no discrimination which would render such a classification possible. 4. All cases of duration less than twelve months. a. Earle's 15,697 cases, at 23 British asylums. Be- coveries 47.49 per cent. b. Chapman's 69,983 cases, at 46 British asylums. Becoveries 46.52 per cent. c. Earle's 8063 cases, at 15 American institutions. Becoveries 38.59 per cent. 5. All recoveries, calculated on all admissions. a. Chapman's 93,443 cases, at 46 British asylums. Becoveries 37.95 per cent. b. Earle's 33,318 cases, at 39 [15 + 24] American institutions. Becoveries 29.15 per cent. c. Earle's 23,052 cases ; 3d period at 20 American institutions. Becoveries 29.91 per cent. d. Earle's 14,372 cases ; in one year at 58 American institutions. Becoveries 27.88 per cent. It will be perceived that, so far as these statistics are an index, the recoveries in British asylums, both of recent cases and of all cases admitted, exceed the recov- 226 THE CUEABILITY OF INSANITY. eries in the American institutions by between eight and nine per cent. The most important general conclusions to be derived from the statistics included in this Study, are, first, that the old claim of curability in a very large majority of recent cases is not sustained, and that the failure to sus- tain it is more apparent and more striking than at any antecedent time ; and, secondly, that the percentage of reported recoveries of all cases received at the hospitals in this country still continues to diminish. It is believed that this diminution is, in part, to be attributed to the admission of a larger proportion of chronic cases, and of cases of greater degeneracy from their origin ; in part, from the increasing — though, as there is good reason to believe, still far from universal — practice of not reporting, as recoveries from insanity j either mere restorations from a drunken debauch or forced temporary suspensions from habitual intoxica- tion ; and, in part, perhaps, from the adoption of a higher degree of improvement as the standard or cri- terion of recovery. It may be that there is still another cause of that diminution. Drs. Bucknill and Tuke, in their treatise upon insanity, mention what they call " cooked" statistics. It is possible that, in the United States, this class of published results is decreasing, and that the reported statistics are more generally given to the public in the spirit of a conscientious loyalty to scientific truth. In conclusion, I would express the hope that the time is not far distant at which the American Association of Superintendents will so perfect its statistical system as to make a distinction between persons and cases, and THE CURABILITY OF INSANITY. 227 enable the reader to learn how many of the reported recoveries are first recoveries, and how many subse- quent to the first. This improvement was made in the Massachusetts statistical tables, as already mentioned, in 1879 ; and in those of the British Medico-Psychologi- cal Association, in 1883. Surely the American Associ- ation ought not to lag far behind in the matter. It ought to have been the pioneer. INDEX. PAQE Admissions and recoveries of persons in three years in Massachusetts. 178 Allen, Dr. N., approves this investigation 79 Analysis of 11,000 cases at Worcester Hospital 144 Apparent diminution of recent cases at institutions 69 Approval of this investigation by several superintendents 80 by superintendents and others 92 by Dr. D. Hack Tuke 94 by Sir James Coxe 95 by Dr. W. A. F. Browne 96 by physicians and others 136 by Prof. Ordronaux 138 Are recoveries increased with increased cost of treatment? 84 Awl, Dr. "W. M., reports 100 per cent, of recoveries of recent cases discharged 28 Bacon, Dr. G. M., on repeated recoveries 160 Bancroft, Dr. J. P,, explains recoveries at Concord in 1876-77 66 in 1878-79 103 Bates, Dr. J., on the fallacy of statistics 81 Belief in great curability, origin of 64 Bell, Dr. L. V., estimate of recoveries at McLean Asylum 29 opinion of curability in 1840 27 in 1857 130 prediction of erroneous belief in curability 101 Blandford, Dr. G. P., on curability 51 Brigham, Dr. A., on curability at Hartford Eetreat 36 defines the word recovered as he uses it 37 Browne, Dr. W. A. P., approves this investigation 96 on " The Curability of Insanity" 150 on the American method of reporting recoveries 151 Bucknill, Dr. J., on prejudices against asylums in England 70 Burman, Dr. J. W., on delay of commitment to Wiltshire Asylum... 72 Burrows, Dr. G. M., claims 91 per cent, of cures of recent cases 19 curability of insanity as compared with other severe diseases 45 Cassidy, Dr. D. M., explains recoveries at Lancaster Asylum 159 Causes of decrease in the ratio of recoveries 57 Chandler, Dr. G., recoveries at Worcester Hospital 80 Chapman, Dr. T. Algernon, incurability of patients at Hereford Asylum 73 statistics of forty-six British asylums 199 Clouston, Dr. T. W., explains recoveries in 1880 at Edinburgh 165 in 1881 at Edinburgh 192 Conclusions in regard to curability 56 derived from Study Seventh 226 229 230 INDEX. PAGE Decision of the American Association of Superintendents on repeated recoveries 14 Delay of commitment, supposed causes of 74 Delirium tremens and drunkenness in insane hospitals 67 at Bloomingdale 68 Demonstration of the seven conclusions of Study First 140 Difference of results at Worcester under two superintendents 16 Diminution in the proportion of recoveries 52 of recoveries at Augusta Hospital 52 at McLean Asylum 52 at "Worcester Hospital 53 at Utica Asylum 53 at Hartford Ketreat 54 illustrated by a table 54 in ijecent cases at York Jletreat 198 in American hospitals 210 Brattleboro' Asylum condemned for 8 Disappointment in the use of new remedies 59 Distinction hetween persons smd patients or cases 9 Draper, Dr. J., explains recoveries at Brattleboro' 100 Drunkards reported as not insane 69 admitted to the Scotch asylums 150 Earle, Dr. P., recoveries at Bloomingdale Asylum 38 Eastman, Dr. B. D., analysis of statistics at Worcester Hospital 11 Effect of temperament, or " personal equation," in reporting recoveries 15 Forty-six recoveries of one woman 10 Gait, Dr. J. M., highest percentage 92.3 26 Garner, Dr. W. H., explains recoveries at Clonmel Asylum 105 Godding, Dr. W. W., recoveries at Taunton 49 Gray, Dr. J. P., reports drunkards as not insane 69 Gundry, Dr. K., recoveries at Dayton, 49 Hearder, Dr. G. J., on delay of commitment at Caermarthen 73 Howden, Dr. J. C, on causes of delay of commitment 74 Jacobi, Dr. M., recoveries at Siegburg Asylum 169 Jarvis, Dr. Edward, on curabilitj'- 42 Kirkbride, Dr. T. S., position in regard to curability 37 Ley, Dr. H. Kooke, explains recoveries at Prestwich Asylum 104 Lindsay, Dr. J. M., on delay of commitment to Derbyshire Asylum.. 71 on repeated attacks 166 Macdonald, Dr. A. E., reports drunkards as not insane 69 McFarland, Dr. A., on the fallibility of statistics 34 Mitchell, Dr. Arthur, statistics of curability in Scotland 75 Dr. Samuel, on delay of commitment in South Yorkshire 71 Multiple admissions at Hartford Ketreat 11 at Pennsylvania Hospital for the Insane 11 recoveries at Frankford Asylum 10 at Worcester Hospital 12 of five persons at Bloomingdale Asylum 128 of five persons at Concord Asylum 129 of five persons at Frankford Asylum 128 of five persons at Hartford Ketreat 128 of five persons at Hereford Asylum 147 of five persons at Worcester Hospital 129 statistics illustrated 154 Necessity for this investigation 79 INDEX. 231 PAGE New remedies unsuccessful 69 statistical tables used in Massachusetts in 1880 152 tables reported to the British Association in 1881 167 tables adopted for one year by the British Association in 1882 194 Origin of the belief in great curability c 64 Park, Dr. J. G., analysis of 11,000 cases 144 explains recoveries at Worcester in 1878-79 143 Paterson, Dr. A. S., report of asylums in South Australia 171 Patient recovered six times in one year at Bloomingdale 13 recovered seven times in one year at Worcester 14 Pennsylvania Board of Public Charities on pecuniary benefit from recoveries , 7 Periodical cases at Pennsylvania Hospital for the Insane 182 Pe?'sons distinguished from patients ov cases 9 Eay, Dr. I., on the uncertainty of statistics 31 condemns classification into recent and old cases 35 early course in reporting percentages 35 on recoveries under Pinel and Esquirol 58 on the tendency of reported recoveries to mislead 135 review of his essay, " Recoveries from Mental Disease" 121 Readmissions in Massachusetts of persons discharged recovered 183 Recent cases diminishing at institutions 69 Recovered vs. cured 153 Recoveries at asylums in South Australia 171 at Bethlehem one hundred years ago 59 at Siegburg Asylum.. 169 at the State Hospital, Poughkeepsie, N. Y 191 at 39 American institutions 202 at 24 American institutions 205 at 20 American hospitals; 3 terms of 5 years each 209 at York Retreat, 1796 to 1819 19 at McLean Asylum diminished with increase of cost 85 at McLean Asylum under Drs. Tyler and Jelly contrasted 89 at Worcester under Drs. Bemis and Eastman contrasted 16 apparently increased by changes (Note on) 32 causes of decrease in the ratio of 37 explained at Frankford Asylum 47 at Concord Asylum in 1876-77 66 at Concord Asylum in 1878-79 103 at Brattleboro' Asylum in 1878 100 at Prestwich Asylum 104 at Clonmel Asylum 105 at Worcester Hospital in 1879 143 at Lancaster Asylum I59 at Edinburgh Asylum in 1880 165 at Edinburgh Asylum in 1881 192 fortj'-six of one woman 10 from debaucheries of drink reported as from insanity 68 in one year at 58 American institutions 211 in each State respectively 216 in sectional groups of States 217 in Pennsylvania hospitals 218 in six years at Danvers Hospital 220 of recent cases at Frankford Asylum 47 at 23 British asylums 197 232 INDEX. PAGB Eecoveries of recent cases at 46 British asylums 200 at 15 American asylums 203 per cent, of, larger in New Zealand than in Great Britain 88 ratio of, to perso7is recovered in Massachusetts 186 readmitted in Massachusetts hospitals in 1882-84 223 remarkable, reported at the Athens Asylum 172 resolutions of the New England Pyschologieal Society on reporting 98 resume of, at British and American institutions 224 suggested discrimination between iirst and subscjuent 83 three persons make one hundred and two 158 Reformation of statistical tables in Massachusetts 152 Relapsed cases at the Richmond Asylum, Dublin 166 Remarkable statistics of one hundred and eighteen cases = 154 Reported recoveries affected by reporter's temperament 15 Results with new tables in Massachusetts in 1880 160 of three years' use of new tables in Massachusetts 176 Retreat at Hartford, Basil Hall's notice of 20 Review of Dr. Ray's "Recoveries from Mental Disease" 121 Rockwell, Dr. W. H., recoveries at Brattleboro' 89 Rutter, Dr. H. C, on reported recoveries at the Athens Asylum 172 Seven conclusions in regard to curability 56 Sherlock, Dr. J., on delay of commitment to Worcester (England) Asylum 72 Skae, Dr. F. W., on recoveries in New Zealand 87 Smith, Dr. S. H., statistics at Columbus Asylum 33 Statistics of one year at 58 American institutions 211 in each State respectively 216 in sectional groups of States 217 at Pennsylvania hospitals 218 Stearns, Dr. H. P., recoveries at Hartford at different periods 50 Stokes, Dr. W. H., on curability of recent cases 40 Stribling, Dr. F. T., recoveries at Staunton in 1841 41 Strong, Dr. J., analogy between insanity and other diseases 149 Subsequent history of patients recovered at Worcester 106 in Scotch asylums 152 Suggested discrimination between first and subsequent recoveries 83 The seven conclusions in Study First confirmed 188 Thurnam, Dr. J., formula of curability 60 statistics of York Retreat 77 Todd, Dr., claims 91.3 per cent, of recoveries 21 Tuke, Dr. D. Hack, approves this investigation 94 on the best mode of reporting recoveries 146 demands the number of persons as well as cases 147 analogy between insanity and other diseases 149 Tuke, Samuel, statistics of York Retreat 19 Tyson, Dr., recoveries at Bethlehem two hundred years ago 59 Woodward, Dr. S. 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