On Statistical Tables of the Causes of Insanity
260 Art. VII.? Q :Author: Herbert C. MAJOR, M.D. Edin. “West Riding Asylum, Wakefield.
The writer of an able and thoughtful article in the Medico- Ghirurgical Review, on the Reports of the Lunacy Com- missioners for the year 1876, makes the following1 observations in reference to the study of the etiology of insanity :?” If, with the vast fields for observation before them, the medical superin- tendents of asylums would lend their minds to solve some general questions in the etiology of insanity, they would confer a real benefit on the community, by enabling them to impart, definite instruction to mankind in the art of keeping sane.’1* It cannot fail to be inferred from the above paragraph, by im- plication, that in the opinion of the writer, medical officers of asylums do not lend their minds to the solving* of problems of etiology in insanity, or to the imparting of definite instruction on the subject. And the question arises, whether such a charge is really deserved. The point is a somewhat serious one. Even although the removal of many of the causes of insanity, as they appear at present, may probably with justice be regarded as Utopian, there still, doubtless, are many, to combat which must be regarded as in the highest degree a wise and noble object; and these must be exposed and their influences fairly estimated before steps are taken to encounter them. And this being so, there can be little doubt that those in the position of asylum physicians, I will not. say fail in their duty, but fail to accom- plish all within their reach, if they do not study, and, having studied, record, as accurately as possible, the various causes which have deprived their patients of their reason, and perhaps of their life. But there are few public lunatic asylums in this country, in the annual report of which there does not appear a table setting forth, in a proportion more or less large of the cases admitted, the cause of the mental attack, and that with an apparent simplicity and certainty leaving nothing to be desired. Are not these facts, it may be asked, of the highest value when accumulated year after year ? Do they not furnish most important data? and do they not serve to acquit medical superintendents of anything like apathy in respect to the demonstration of the etiology of insanity ? The answer to all this must, it is feared, be in the negative. It is not easy to over-estimate the practical value which the tables referred to in asylum reports would by this time have acquired, if they had been compiled on a common plan, and that plan a good one. But no common plan has been adopted, and one of my objects is now to urge that?speaking, of course, in a general sense?the statistics are not and cannot be re- liable. It may be that I am wrong, but I venture to think that few thoughtful and experienced alienists would turn to asylum reports for reliable data concerning the etiology of insanity. Far rather would they have recourse to the detailed record of individual cases, and gather their facts therefrom. Let it not be thought that it is intended by this statement to throw doubt on the care and judgment of the compilers of the tables; it is the system of tabulation, as usually followed, which it is contended must be fallacious. Is it urged by some that the tables referred to are not supposed or intended to be exhaustive or accurate ??the reply is ready, and seems to be con- clusive Why give data admitted to be untrustworthy, and as a consequence useless and even misleading ?
It has been stated that the fault lies chiefly with the system of tabulation pursued: the ground for this assertion must be given. Appeal is made to the result of actual experience of the causation of insanity, as the only tribunal. But let the fact first be brought into prominence, that often, if not invariably, in our asylum reports, the aggregate of the figures placed opposite the various causes in the tables is found to agree with the number of cases admitted during the year under con- sideration. Hence it is evident that for each case a single cause has been allotted. Now, without denying that cases may and do occur in which a single adverse circumstance has sufficed to produce insanity, it is maintained that this is the exception and not the rule. The case hangs on the accuracy of the above conclusion. An examination of the case-book records of this asylum affords strong evidence of the truth of my contention. In recording a case, the medical officer, with the history of the case fully before him, and with guidance often from the statements of the patient and from the nature of the symptoms, records side by side with the diagnosis the condition or conditions which fairly appear to have induced the mental attack. Sometimes a single cause is given, but far more fre- quently two or more are recorded, from which it has been found impossible with justice to select one, to the exclusion of the others. All appear to have participated, and probably all have done so. If such is the case, then I think no arguments are required to show how unsatisfactory and misleading must any system of tabulation of causes be which assumes in all cases to have ascertained the cause of the attack and allows no scope for the record of collateral causative influences. And therefore it is that I venture to express the opinion that the statis- tical table of causes, as commonly found in asylum reports, should give place to a system more in accordance with facts and experience, if such can be devised.
In proceeding now to offer, for the opinion and judgment of others, a method of tabulation which I venture to think would meet many of the requirements of the case, and be free from the sources of fallacy inseparable from the system which usually obtains, I have merely to express a hope that it may be con- sidered worthy of being weighed in the balance and dealt with strictly on its merits.
The feeling of utter failure experienced in endeavouring to draw up with accuracy a table of causes in the usual manner, led me to consider whether it would not be possible to devise a system which, while being simple and easy of application, might at the same time embody more facts than the usual method, and so be more truthful and accurate. And, finally, a scheme suggested itself, to describe and illustrate which will now be my object.
The course proposed is extremely simple. It is (1) that in recording each case, with respect to its causation, the circum- stances, however few, or however numerous, which seem, on the information available, to have exercised a causative influence, should be fairly stated ; and (2) that in placing the supposed causes in a tabular form, they should be simply added together, like with like, and irrespective of the number of cases under consideration. To give an illustration of the plan suggested, I take six cases at random from the case-book.
Name. # Causes. M. S. Hereditary tendency (to insanity), alcoholism, previous attacks. M. A. S. Over-lactation, grief. E. P. Old age, grief. S. J. C. Hereditary tendency, climacteric period. S. L. Old age. _ E. A. H. Grief, privation, climacteric period. x Adding and tabulating like causes in the above six cases the results may be expressed as follows : Hereditary tendency contributed to the production of Alcoholism ? i r” Over-lactation ? 1 Grief ? 3 ?d age ? ? .2 Climacteric period ? ? 2 Privation ? 1 37 M 1
Of course, if desired, the subdivision into moral and phy- sical causes can, under this system, be made in the usual way, and probably the table would derive additional value by the ‘per- centage value of each causative agency being given. These are matters of detail; the essential point being that of no single cause is it stated that it has produced a given number of cases, but that it has been concerned in their production.
The chief advantage claimed for the system, as now sub- mitted, has been already pretty clearly indicated in the course of my remarks. Instead of pausing in perplexity over cases to the causation of which several influences appear to have contributed, and endeavouring to weigh their relative importance, so as to be as little incorrect as possible in stating the cause, there is nothing to do but to record carefully and conscientiously all the influences which appear to have played a part. Take a case (no uncommon occurrence) in which there is shown to have been hereditary tendency to insanity, mental anxiety, and alco- holic excess as facts in the history. Who shall decide on which to throw the responsibility and which to exclude ? Is it not more probable that all have played a part, and that to attempt to dissociate them is impossible, and must fail ? The system proposed provides for any such contingency, and gives to all the adverse influences a place.
But it may be urged that the value of positive data as to the number of cases of insanity traceable to a given cause, and that cause only, is too great to be given up. It would certainly be so if it could be shown that in a majority of cases it were possible to ascertain the fact; but if, as I have contended, this is impossible, then, as it appears to me, it is better to remain satisfied with data, which if not so definite and precise as could be wished, nevertheless express important facts and furnish reliable information.
It may be objected, in the second place, that by the pro- posed method all causes would appear to be of equal potency: that is to say, no special indication is given of those which singly have or appear to have occasioned the insanity. I must admit the force of the objection, which, however, applies equally well in reality, if not on paper, to the system commonly in use. Practically, the most important cause will be that the occurrence of which is most frequently noted, and this is at once indicated in the method of tabulation proposed.
Finally, it may be urged that it is safer in stating causes to give too little than too much, that it is better to omit the record of some condition which may have been causative, rather than to introduce as such those which may have had no influence. Possibly this is so. Practically, however, with care, serious error in over-statement, will, I think, be usually avoided. Let it be said, in conclusion, that the primary object of the foregoing remarks has been to bring into prominence the in- adequacy and unsatisfactoriness of statistical tables of the causes of insanity as at this time commonly drawn up, and only in a very secondary sense to present for consideration another method. When it is admitted, as it can hardly fail to be, by those who have given their attention to the subject, that in most instances the cause of the insanity in a given case can only be adequately represented by the entire history of the case, the conclusion follows almost of necessity that statistical tables of causes must at best be imperfect. Doubtless it is true that to any system which may be proposed, objections?and valid ob- jections?will not be wanting. But none the less should it be the endeavour of asylum physicians, in presenting statistics, to see that they impart useful and reliable information. It is in regard to a system which fails, I consider, in this respect, that I have ven- tured very earnestly to record my non placet, and feel assured that, to this extent at least., I shall have the support and concur- rence of those whose experience and learning entitle their opinion to respectful consideration. There is, as far as I can see, for asylum physicians, in regard to the question raised, no escape from one of the two alternatives before them?for I would dis- miss from consideration that of inaction. If the statistics of causes now accumulated have the merit of reliability, they ought to be utilised for the general good. But if, from any reason, they are faulty and misleading, then without more ado it is advisable that a more reliable record should be substituted, which may in time lead up to sound and far-reaching con- clusions.
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