XX : los discursos sobre la cura en la medicina mental española , 1890-1917 The treatment of madness in the nineteenth and twentieth centuries : discourses about curability in Spanish mental health care , 1890-1917

This article studies the discourses about curability constructed by Spanish mental health practitioners in the transition from the nineteenth to the twentieth century. While in the 1870s and 1880s the predominant discourse promoted by doctors attached to private institutions was extremely optimistic, it subsequently changed and became more pessimistic regarding treatment outcomes. However, given phrenopathists’ professional needs, they continued to profess more or less unshakeable confidence in the therapeutic abilities of psychiatry. The reception of new nosologies, such as Kraepelin’s, depended in part on contemporary mental health practitioners’ stance on curability and was accompanied by ambivalence.

S panish psychiatry underwent a process of incipient institutionalization in the second half of the nineteenth century.The way that phrenopathists constructed a discourse promoting their ability to offer effective treatments so as to justify their importance in society and to help establish their own medical specialty has been studied from a theoretical standpoint based on the sociology of professions (Huertas, 2002).Defense of the usefulness of mental health care focused on two aspects: on the one hand treatment, as is logical, and on the other the skill needed to differentiate the mentally ill from criminals, which conferred the ability to determine criminal liability (Campos, Martínez Perez, Huertas, 2000, p.75-84).
On the organizational level, from the 1860s through the 1890s, the network of care consisted of two differentiated spaces.On the one hand, there was a network of barely medicalized state asylums whose deficiencies were constantly being denounced, paralleled by a set of private centers run as businesses and clearly intended to make a profit (Comelles, 1988, p.49-92).Representatives of the latter developed an optimistic discourse about the specialty's ability to offer cures at a time when the treatments available were severely limited (Plumed, Rey, 2006).The most relevant author to direct a private institution was Juan Giné y Partagás (Rey, 1982).When we analyze the interests behind this author's optimism (besides that of defending the profession), we cannot ignore his desire to promote his business, which depended on admitting fee-paying inmates who expected that their madness would be cured.In his theoretical work, he understandably stressed the usefulness of the moral treatment.
There is an example of this in his Tratado teórico-práctico de frenopatología o estudio de las enfermedades mentales fundado en la clínica y la fisiología de los centros nerviosos (Theoretical and practical treatise on phrenopathology, or the study of mental illness based on the diagnosis and physiology of the nervous centers): with respect to madness, a good asylum offers the greatest potential for a cure … if all those aspects concentrate on exerting an influence that is constant, hygieno-therapeutic in nature and both physical and moral in action, in other words in an asylum designed according to the rules of the art, the curative effect of medications and moral agents is multiplied, making non-recovery from mental illness relatively rare (Giné y Partagás, 1876, p.309).
He did not limit himself to addressing only doctors to promote the idea that madness was curable.Giné y Partagás also called for educating the general public about phrenopathic knowledge, so that people would recognize the importance of the field.This, according to the author, would help both to eliminate superstition and spread the idea that madness was an illness that could be cured by medicine for the mind, and also acknowledge the worth of phrenopathists.He stressed the importance of making people aware that treatment would only work if it was started in a timely fashion, so that it was vital for a good outcome that families bring the patient in promptly (Giné y Partagás, 1903).In the introduction to his book Misterios de la locura (The mysteries of madness), a work that belongs in a group of novels on scientific topics written by prestigious physicians in the second half of the nineteenth century (Huertas, 2010), Giné y Partagás said that his goal was to clarify the concept of mental illness, "to popularize it, by dressing it up in as attractive and pleasant a way as the gravity and importance of the issue allows" (1890, p.6).The protagonist, Eulogio Higiofrén, suffers an episode of madness as a result of a receiving powerful emotional shock, and has to be admitted to an asylum.The second half of the book is devoted to a detailed description of the physical and moral treatments he receives in the Nueva Belén hospital, which lead to a complete cure.The phrenopathist who attends him explains his therapy as follows: "madness is an illness like any other, as curable as any other, if, as in your case, the powerful remedies of medicine for the mind are applied in time" (Giné y Partagás, 1890, p.208).
This propaganda discourse was common among other private institutions, such as the asylum run by José María Esquerdo, a key figure in psychiatry in Madrid thanks to his role as disseminator and organizer, although he was more limited in his ability to generate theory (Huertas, 2004;Rey, 1983).He was the director of the Carabanchel Alto asylum, a private institution catering to affluent patients.Some of his disciples, such as Ángel Pulido and Manuel Tolosa, promoted it in informational articles and books as a modern asylum where sick people were easily cured (Villasante, Huertas, 1999;Huertas, 2002, p.47-71;Villasante, 2005).
Discourses in Spanish psychiatry evolved toward pessimism regarding treatment in the early twentieth century.Despite this tendency, Spanish phrenopathists continued to defend their field's ability to provide cures, even though with reservations and much more moderately than in the previous century, in relation to their professional needs at that particular moment in history.This attitude influenced the assimilation of current theoretical models at the time, fundamentally Kraepelinian psychiatry, which was questioned because of its pessimism.Likewise, those alienists who practiced privately maintained an optimistic discourse that fit the particular nature of their professional practice.This article aims to make a contribution to a little-studied period in Spanish psychiatry by analyzing the processes and variables at work from the 1890s until 1917, at which point the appearance of the so-called Madrid School boosted optimism about therapeutic outcomes in psychiatric discourse (Plumed, Rojo, 2010).

The survival of the optimistic discourse about moral treatment
Although confidence that mental illness could be cured had declined, after the turn of the century many phrenopathists whose training and professional development dated back to the nineteenth century continued their strikingly optimistic defense of the moral treatment as essential to curing madness.
Arturo Galcerán Granés was the most important disciple of Giné y Partagás and, after his teacher, the most important representative of the Catalan psychiatric school at the turn of the twentieth century.His early work took place at the Nueva Belén asylum, where he adopted the optimistic view of recovery inherited from his mentor.He briefly succeeded Antonio Pujadas as director of the San Baudilio asylum until 1895 (Rey, 1985).Speaking of treatment in his introduction to a book by Martínez Valverde, he remarked upon the specificity of medications in psychiatry and declared that medical knowledge at the time could tell not only what causes or symptoms could be treated, but also on what specific part of the central nervous system [a given] drug would act (Galcerán Granés, 1900, p.XVII).Although he was criticized by some, in one article he attributed the lack of efficacy of medications to the fact that "they were not employed with rigorous precision, following the precise indications" (Galcerán Granés, 1903, p.14) and insisted on the specificity and usefulness of pharmacological treatments.
He maintained the same optimism about the moral treatment.In another article on care for the mentally ill, he describes asylums as curative institutions and proposed improving them by treating patients separately according to the pathology they suffered.He suggested admitting only patients who could be cured and suggested in-home care for the chronically ill, except for those who could not adapt to the family or social environment, as well as for those who resisted treatment or were a danger to themselves or others (Galcerán Granés, 1907a, 1907b, 1907c, 1907d).
Joaquín Martínez y Valverde was a disciple of Arturo Galcerán Granés and worked under his mentor for a decade as assistant director of the asylum at San Baudilio de Llobregat.He resigned from the position in 1895.Some years before his death in 1902, this author wrote the last Spanish psychiatric treatise of the nineteenth century, the Guía de las enfermedades nerviosas y mentales, con nociones sobre la terapéutica, deontología y medicina legal frenopáticas (Guide to nervous and mental illnesses, with notions on treatment, professional ethics and forensic medicine in phrenopathy).In this book, although he was very influenced by degenerationism, Martínez y Valverde maintained a strikingly optimistic attitude towards treatment.He stressed that, for a good prognosis, patients needed to be admitted to a private institution in the early stages (Martínez Valverde, 1900, p.276), since sending them to a state asylum "exerts a disastrous effect on their psychic state" (p.254).He believed that the classic moral treatment was phrenopathy's most powerful weapon.After forbidding contact with family members, he laid out the basic elements of treatment designed to yield a cureisolation and the moral order of the institution: the tyranny he exercised over his own [relatives] ceases, and some of the superiority he feels often disappears; he is subject to the influence of the regime and the discipline he sees around him, which is the same for everyone.While at first he may protest, soon he becomes more calm, thanks to the regularity with which everything around him is carried out … thus, ceasing to find anything to feed his illness, little by little he regains placidity of spirit (Martínez Valverde, 1900, p.279).
Juan Barcia Caballero was the most eminent figure in psychiatry in early twentiethcentury Galicia (Villasante, 2001).He directed the Conjo asylum, which was created in 1885, and was the most important one in the area.At that time, its function was custodial (Barcia Salorio, 2001).His optimism regarding recovery was likewise focused on the moral treatment, at the expense of pharmacotherapy: "the inefficacy of the majority of the medications for treating this illness is well known; precisely for that reason, I have been advocating … for moral treatment of the insane" (Barcia Caballero, 1999, p.122).His practice was based on the classic principles described earlier -isolation, persuasion and suggestion -as well as the authority of the figure of the phrenopathist, defined in paternalistic and religious terms: "the employees of these homes and the patients who inhabit them form a true family, united and connected by the bonds of kindness and charity" (p.35).

Between pessimism and confidence in curability
By the early twentieth century, most phrenopathists were citing very different cure rates for mental illness than those listed earlier.While Antonio Pujadas y Mayans (1872, p.6), founder of San Baudilio de Llobregat asylum, wrote that the cure rate was 70%, Antonio Rodríguez Morini (1907a, p.359), writing three decades later, quoted the figure as being under 2%.Rodríguez Morini was a disciple of Giné y Partagás.He trained in phrenopathy in the Nueva Belén asylum, succeeded Arturo Galcerán Granés as director of the San Baudilio asylum in 1895, and in 1903 founded the Revista Frenopática Española, one of the most important psychiatric science journals during the early decades of the twentieth century (Jordá, Rey, 2007).
We must bear in mind that the (1872) statistic comes from a pamphlet written to promote a private institution caring for fee-paying patients, while the more recent (1907) one comes from a report published in a specialized journal about an institution that took mainly poor patients subsidized by the provincial government of Barcelona (Rodríguez Morini, 1905, p.336) and therefore did not need to advertise its strengths to an affluent readership.However, the fact is that, in the early twentieth century, the idea that mental illness was a chronic condition with scant chance of a cure grew stronger in Spanish psychiatry.This can be attributed to several factors.One of them was legislation, since a royal decree published in 1885 transferred decision-making powers regarding the admission of mental patients to their families and the local authorities, thereby devaluing the role of the phrenopathist (Comelles, 1988, p.92-101).Another reason involves the type of care provided.We have to remember that in Spain the nineteenth-century asylum was a barely medicalized space.Institutions did not follow the therapeutic criteria of the time and were mostly run by religious orders, so that the physician's role was often reduced to treating common illnesses among the inmates (Campos, Huertas, 2008, p.477).The little real psychiatric care that existed was found in private asylums, but these privately-run centers deteriorated as a whole in the last decades of the nineteenth century, undermining the image that had been created of their brilliant efficiency.An example can be seen in the case of the San Baudilio asylum, mentioned earlier, which ran into difficulties in the 1880s as a clinical and business project (Espinosa, 1966, p.110-111) and ended up as part of the organization run by the Order of San Juan de Dios.This network of asylums, which included several of the most important institutions in the country, such as the Ciempozuelos asylum in Madrid and the Santa Águeda in Guipúzcoa, became quite well-known and seems, according to statements by leading figures in the order, to have granted its physicians a fair amount of professional latitude (Ayucar, 1905).
Another factor was the introduction of degenerationist theory.In the first two decades of the twentieth century, degenerationism was the predominant theoretical model among Spanish psychiatrists.The introduction of degenerationist ideas in Spain took place in a way that differed from France, where it was also an important part of the process of professionalizing French psychiatry (Dowbiggin, 1991).Initially, degenerationist theory was used in Spain in the field of forensic medicine, since it gave phrenopathists an important way to justify their role as experts in spaces beyond the medical field, in this case forensics.Enormous publicity was given to cases in which doctors argued that a mentally ill person could not be held liable, using supposedly objective data based on degenerationist doctrine (Campos, Martínez Pérez, Huertas, 2000, p.84-112).In the 1880s, it began to be introduced into clinical work, and by the 1890s it was widely used (Plumed, Rey, 2001;Campos, 1999b).Although degenerationism has been linked to the rise of the concepts of chronicity and incurability in French psychiatry (Huertas, 1998), in Spain, phrenopathists were not nihilistic regarding the ability to cure madness, although their theoretical framework did adjust to the degenerationist paradigm.This can be interpreted as a necessary form of professional legitimation.Given the scant attention paid to the hygienist discourse by alienists during this period -the opposite of what was happening in France (Campos, 1999a, p.187) -phrenopathists needed to display the value of their specialty, and could not stop claiming that psychiatry could cure patients.However, the chronicity of many forms of mental illness was taken for granted and a more prudent and limited vision of the specialty's powers was promoted.
In the aforementioned report on San Baudilio de Llobregat addressed to the provincial government authorities in Barcelona, Rodríguez Morini (1907a) gave two reasons for the extremely low cure rates.In the first place, he argued that many patients tended to be admitted to the asylum late, as shown by the promotional discourse of Giné describing delays on the part of government bodies handling admissions of mental patients.Also, the institution only allowed patients to leave if they were fully cured, unlike the centers that discharged inmates prematurely to improve their statistics: "by doing that we would merely be deceiving the public and deceiving ourselves" (Rodríguez Morini, 1907b, p.51).In another report that same year, he justified the low number of discharges due to improvement as stemming from the major bureaucratic obstacles to readmitting patients, since if they relapsed, their discharge was legally permanent, so families refused to take their relatives out of the asylum (Rodríguez Morini, 1907a).Here, the author makes no reference to the poor response to treatment of most psychoses or to the therapeutic limitations of the specialty.
Luis Martín Istúriz, director of the asylum in Palencia, presented a report in which he quoted a 4% cure rate for the asylum population.He attributed the figure both to people's ignorance about the efficacy of active treatments and to the lack of half-way houses for patients who had been cured in his center, who relapsed as a result.He attached such importance to early admission that he claimed cure rates of up to 15% in private patients, thanks to the fact that they had been admitted before the chronic stage (Martin Istúriz, 1907).In his report the following year, he noted a rise in admissions which he attributed to widespread awareness of the idea the only way to cure madness was through a hospital stay.He contrasted the 4% cure rates for government hospital inmates to an 8% rate for private patients, which he attributed to the fact that in the former the "opportunity for treatment was lost while they wandered around in town or were imprisoned in hospitals because the provincial government budget required economizing on inpatient stays" (Martín Istúriz, 1908, p.28).
Joaquín Gimeno Riera was a staff physician from the 1910s on; later, he was became the director of the Zaragoza asylum.In an article published in a general medicine journal, he wrote of the need to promote awareness of phrenopathic knowledge in order to combat ideas about the incurability of mental disorders.He stressed the importance of early admission of the patient to an asylum in order to obtain a cure, since other open environments, such as colony-asylums and workshop-asylums, were nothing but "a dream, above all in Spain," where at that time the only institutions available were traditional ones (Gimeno Riera, 1911a).In another publication, emphatically titled Las grandes innovaciones de la terapéutica mental moderna (Great innovations in modern mental health treatment), he claimed to be confident that madness could be cured and listed novel treatments; not only non-restraint therapy, which had been discussed since the mid-nineteenth century, but also the open door regime, clinotherapy (bed-rest) and prolonged warm baths, although he acknowledged that this latter method had been used for years in centers such as San Baudilio.He was a proponent of the "open-door" policy and of placing mental patients in unknown foster families for treatment as an alternative to the traditional asylum, a change in care that demanded deep knowledge on the part of the physician and of philanthropists who were promoting the cause (Gimeno Riera, 1907, 1908, p.42).In other words, he was starting to promote a discourse about the usefulness of extra-institutional treatment modes, although they did not develop further at that point in history (Campos, 2004, p.104).
Abdón Sánchez Herrero, the son of a professor of internal medicine with the same name, was involved in introducing hypnotism to Spain (Diéguez, 2003, p.224).He directed the Sanatorium del Pilar in Madrid in the early decades of the twentieth century.It was a charity institution providing care for poor patients.In general, although in some clinical cases he acknowledged the marginal efficacy of available treatment methods, such as clinotherapy and organotherapy in a case of dementia praecox (Sánchez Herrero, 1913b), his writings show a clearly optimistic vision of the efficacy of the moral treatment in many types of madness (Sánchez Herrero, 1907, 1918b, p.126).If treatment failed, he, like all the other authors cited, blamed the patient for leaving the center too early (Sánchez Herrero, 1911, p.104, 1918a, p.126).Although his outlook was clearly degenerationist, he was extremely optimistic about the efficacy of treatment for psychopathologies and he defended the present and future usefulness of the classic moral treatment.
The phrenopathists who worked primarily for the army did not focus on treatment.They were influenced by the fact that much of their work involved trying to detect simulators and diagnosing potentially dangerous patients or individuals who were breaking service rules, such as deserters (Juarros, 1913).As in forensic psychiatry, the theory of degeneration, with its concept of physical stigmata, allowed for an objective standpoint under the guise of a scientific model that allowed the doctor to adopt the role of expert in identification and diagnosis, which led these doctors to champion that theoretical stance.Despite that, they continued to defend the curative ability of the specialty.
One of the most well-known figures was Antonio Fernández Victorio y Cociña, who has been seen as the founder of the Military Psychiatry School (Escuela Psiquiátrica Militar) in Madrid.He was a professor of internal medicine, although he specialized in neuropsychiatry and eventually directed the Military Psychiatric Hospital (Hospital Psiquiátrico Militar) at Ciempozuelos (Valenciano, 1977, p.86).In an article published in a medical journal, he wrote of the general prejudices surrounding madness.He protested against the widespread view of mental illness as an incurable disease: "madness is a disease, and as such, its sufferers are entitled to all possible kindness and care … all the more so since it is often curable and even more frequently avoidable" (Fernández Victorio y Cociña, 1916, p.383).César Juarros was an author whose field of study covered multiple areas.He was influenced by psychoanalytic doctrine, was very active as a promoter of psychoanalysis and became involved in politics (Samblás, 2000).In an article on military psychiatry, although he argued that madmen tended to relapse and insisted on the need for permanent supervision of patients in recovery and the need for them to remain off work, he presented data provided by the military health authorities, in 1904, listing a 25% cure rate for patients who were then passed as "fit for service" (Juarros, 1907, p.81).In his book Psiquiatría forense (Forensic psychiatry), in the chapter devoted to treatment, Juarros (1914, p.146-152) writes that "a large number of mental conditions can potentially be cured," although he limited them to epileptics, neurasthenics and morphine addicts.
As was pointed out earlier, forensic medicine was crucial for the process of institutionalizing psychiatry in Spain.At the beginning of the twentieth century, degenerationism was the most widely-held psychiatric approach among forensic physicians.Given that their role did not involve clinical and therapeutic practice, it is understandable that their most pessimistic vision of the doctrine should have related to the curability of mental patients.
Tomás Maestre Pérez and Antonio Lecha-Marzo were two important figures in Spanish forensic medicine in the early twentieth century (Huertas, Martínez Pérez, 1993).Tomás Maestre, a professor of forensic medicine at the Universidad Central in Madrid, believed that all mental patients were degenerates.His attitude regarding the treatment of psychosis was nihilistic, and he advocated only prophylactic social intervention measures: religion-based education, and preventing masturbation and other causes of nervous excitation (Maestre Pérez, 1906a, 1906b, 1906c, 1906d).Antonio Lecha-Marzo, professor of forensic medicine at the Universidad de Granada, summed up the theoretical standpoint of the different degenerationist authors in an article.He subscribed to Maestre's belief in the importance of degenerative processes in the pathogenesis of all forms of madness and explained that insanity in the degenerate was a chronic condition, with no therapeutic goals (Lecha-Marzo, 1915).

Chronicity and the use of nosology
Lanteri-Laura has studied how the concept of chronicity evolved in French psychiatry and the factors affecting it.In his view, it was related to phrenopathists' need to have a large number of in-patients so that the asylums could support themselves financially through the inmates' agricultural labor, which was seen as therapeutic.This notion was constructed upon three elements: chronic delusional disorder, degeneration theory and the new concept of dementia (Lanteri-Laura, 1972, p.555).
Chronic systemized delusional disorder was defined as a mental illness by Valentin Magnan in 1892.It was a psychotic condition that involved four phases: incubation, paranoid delirium, megalomaniac delirium and dementia.The concept received various critiques, above all for its theoretic nature and its failure to correspond to clinical experience (Pichot, 1982).In Spain, theoretical debate on the subject remained active despite the introduction of the concept of dementia praecox (Plumed, 2008, p.439-440).On the other hand, the concept of dementia underwent an important shift at the end of the nineteenth century since it came to be defined in relation to a cognitive paradigm, meaning that the key symptom of the clinical condition became intellectual decline in the elderly (Berrios, 1995, p.46).
According to some data, neither of these diagnoses was very widely used in Spain.In some asylum medical reports published at the time, patients were classified to show the proportion suffering from each disorder.None of these reports cites chronic systematized delusional disorder in the nosological categories published in the literature (Martínez Valverde, 1900, p.187-197).
In 1904, in San Baudilio de Llobregat, Rodríguez Morini (1905, p.338) listed 2% of the patients as being diagnosed with systematized delusions and 9% as terminal senile dementia.In the report for 1907, the same author listed the percentage of patients admitted for systematized delusions as 5% and 14% for terminal senile dementia (Rodríguez Morini, 1908, p.360).
Ricardo de Añíbarro was the medical director at the Santa Águeda asylum in Guipúzcoa.In his report for 1908, he listed 8% of patients admitted for systematized delusions and 6% for secondary senile dementia (Añíbarro, 1908, p.61).In his report for 1910, the number of patients with systematized delusions was listed as 5% and vesanic and senile dementia as 11%.
These data suggest that in Spain the concept of chronicity was not based on diagnoses of dementia and chronic delusions, but that illnesses corresponding to the nosology of the previous century were given much more weight and were already linked to the idea of incurability.Thus, the medical report for 1908-1909by Rodríguez Morini (1910, p.323) states that 90% of conditions diagnosed were chronic, "that is to say, incurable," and that the most frequent diagnoses were "epileptic madness, imbecility, idiotism, terminal dementia and general paralysis, as well as paranoias and insanity among degenerates." At the beginning of the twentieth century, Kraepelin's ideas began to be discussed in Spanish psychiatry.Spanish phrenopathists were resistant to the German author's theoretical model for the various reasons analyzed earlier, among them its pessimism regarding treatment (Plumed, 2008, p.448-449).In the sixth edition of Kraepelin's treatise, published in 1899, the number of pages devoted to treatment was very small compared to clinical approaches or etiology.Regarding dementia praecox, he wrote that "Since we do not know the current causes of dementia praecox, its treatment can only aim to combat the different symptoms.At the beginning, in acute and sub-acute cases, putting the patient in an asylum is useful to avoid accidents and suicides" (Kraepelin, 1899, p.160).Many authors, as we shall see, considered his definition of this new illness to be too broad and pessimistic.
Both the concept of dementia praecox and that of manic-depressive insanity included a temporal dimension in their definitions as mental illness.In the previous century, vesanic dementia was seen as an avoidable complication of any one of the forms of madness (Berrios, 1995, p.40) with the exception of general paralysis, which was the first mental illness to include chronological evolution as defined by some authors (Bercherie, 1980, p.75).Subsequently, it was seen as an inevitable stage in certain mental illnesses, such as dementia praecox and chronic systematized delusional disorder.Diagnosing a patient with a mental illness like dementia praecox meant that, regardless of his clinical state at the outset, he was eventually destined to go into an irreversible decline.As for manic-depressive psychosis, even though Kraepelin (1899, p.315-317) held that the prognosis was good for isolated episodes of manicdepressive insanity, especially in cases of manic excitation, the probability of relapse in the complete form was seen as high.Many phrenopathists took a pessimistic view of diagnosis, História, Ciências, Saúde -Manguinhos, Rio de Janeiro at least in their theoretical writings.Thus, Gimeno Riera (1910, p.39) argued for a poor prognosis for manic-depressive insanity: "experience obliges us to share the opinion of the many contemporary alienists who hold that mania and melancholy always recur… In our 8 years leading a service responsible for over 250 mental patients, we have not seen a single non-recurring case of mania or melancholia."For Fernández Victorio y Cociña (1915, p.396-404), mania was merely a symptom that occurred during the course of incurable diseases, such as manic-depressive insanity.
Rodríguez Morini, cited earlier, helped to introduce the concept of dementia praecox in Spain (Plumed, 2008).In an article on the topic, he pointed out how rare it was for asylum patients to suffer from chronic systematic dementia: "Dementia praecox is undeniably one of the most frequently-observed forms of psychopathy in asylums; it leads also to the incurability of most of the patients suffering from insanity who are admitted to asylums" (Rodríguez Morini, 1903, p.168).
On the other hand, in the asylum he directed, there was a greater tendency to diagnose mental illnesses whose prognosis was potentially favorable and less use of diagnoses based on Kraepelin's nosology.In the 1904 report on San Baudilio, 2% of patients were diagnosed with double insanity.However, 26% of the diagnoses involved the classic conditions of mania and melancholia.As regards the diagnosis of dementia praecox, it was suffered by 6% of the inmates (Rodríguez Morini, 1905, p.338).In the 1906 medical report, he diagnosed 7% of the patients with dementia praecox and 3% with manic-depressive insanity, while 19% were labeled as having manic or melancholic syndrome.The diagnosis of double madness was limited to 20% of the mental patients, and he specified that recovery referred to the most recent episode (Rodríguez Morini, 1907a).
A similar attitude can be seen in other institutions.In the 1908 report for the Santa Águeda asylum, manic and melancholic conditions were listed as 25% and manic-depressive insanity as 7%.Dementia praecox was listed as 14% (Añíbarro, 1908, p.61).In a report from the same asylum in 1910, 23% of the patients were suffering from manic or melancholic syndrome, 7% from manic-depressive insanity and 17% from dementia praecox.On the other hand, 40% of the patients in recovery had suffered a manic or depressive condition and 9% had manic-depressive insanity (Añíbarro, 1911, p.60).In the 1908 demographic statistics for the Palencia asylum, 8% of the patients suffered dementia praecox, 17% were diagnosed with a melancholic or manic condition and 6% with manic-depressive psychosis.Of the cured patients, 31% had suffered mania or melancholy while 12% had manic-depressive psychosis (Martín Istúriz, 1909, p.55-56).
These figures seem to indicate that phrenopathists tended to avoid labeling the patient with manic-depressive insanity and resorted more frequently to the classic model of mania or melancholy.Besides, various institutions considered patients with manic-depressive illness who had recovered from a mood episode to be cured, without taking further relapses into account.
These figures also suggest that the diagnosis of dementia praecox was used moderately frequently; it did not become as widespread as Kraepelin had hoped, nor did it replace diagnoses based on the classic nosology.As befits the original definition of the disease, there are no cases of recovery listed in any of the reports.
One way of avoiding the pessimistic view of treatment associated with dementia praecox was to use the term as a syndrome and not as a nosological entity.It could be applied to conditions with similar symptomatology to the disease, but in which the patient evolved favorably, which did not match Kraepelin's definition.Rodríguez Morini (1910, p.323), in his medical reports for 1908-1909, named the following as diseases that had been cured in his center: "manic and melancholic syndromes, toxic and infectious insanity, acute episodes of degeneration, hysterical insanity and dementia praecox syndrome." Debate about the curability of the diseases created by Kraepelin was common.For example, Joaquín Gimeno Riera (1911b, p.159-160), writing about dementia praecox, did not hesitate to suggest a slightly more favorable prognosis than the German author, and criticized his broad concept of the disease.Miguel Gayarre, director of the Ciempozuelos asylum (Giménez Roldán, 2002), wrote a report in 1909 in which he defended the large number of patients discharged from his center and raised the issue of incurability in psychiatry.According to this author, there was a lack of accuracy in prognoses for mental disorders, and he rejected a definition of mental illness based on incurability, because clinical experience showed that patients did improve.He cited Kraepelin's concept of paranoia as an example of this (Gayarre, 1912, p.152).

From the asylum to private practice
By the end of the nineteenth century, phrenopathists were looking for other spaces in which to exercise their profession, such as private practice and home visits (Comelles, 1992).This new activity profile required an optimistic discourse that affirmed the inefficacy of the moral treatment.They were clearly seeking economic benefits, since private practice yielded a much more attractive income.For example, Luis Simarro, one of the most well-known phrenopathists of his day (Vidal, 2007), has been studied by Antonio Rey, who explains that Simarro's practice yielded an income of about 10,000 pesetas a year, ten times more than the salary of a psychiatrist working in the public sector (the director of the Valencia asylum earned 1,750 pesetas a year and a staff physician 1,500 pesetas a year).Although the majority of the diagnoses in medical histories were cases of melancholy or hysteria, he received all sorts of patients: general paralytics, epileptics, the delusional and those with dementia praecox.The treatments he prescribed were primarily psycho-pharmaceutical: bromides, chloral hydrate, and Veronal (a barbiturate) (Rey, 1998, p.324-327).Several of Esquerdo's disciples took this alternative professional route.One of them, Vicente Ots y Esquerdo (1893, p.506), a phrenopathist who had trained at Carabanchel Alto, did not hesitate to criticize his mentor's therapeutic methods in defending his own decision: [there is] a celebrated alienist who runs a private asylum near Madrid and has acquired some renown in mental health without having scientifically demonstrated his competence… [yet] despite the infinite number of failed prognoses he records, he has not so far mended his ways.A madman suffering persecutory delusions who enters his asylum is immediately granted assurances of a cure within a short time, all the more so if he pays for first-class accommodations and, as may naturally be supposed, before an error is admitted, the family becomes weary and disheartened, leading them to withdraw the deranged man from this alienist's care, so that he is left with the conviction that a cure was not achieved because of the family's lack of constancy.
Until that point, recovery was seen as guaranteed by moral treatment under the expert direction of the alienist.Faced with this collective therapy model, these authors argued that patients could be treated more efficiently in their own homes, on a one-to-one basis.To support this argument they criticized two key factors in the recovery process in the moral treatment model: the importance of isolating patients from their families and early admission.In 1885, Timoteo Sanz y Gómez, who was also a disciple of Esquerdo's and formerly the staff physician at the Carabanchel Alto asylum, set up a private practice to treat mental illnesses.He praised the existing therapeutic models as important and defended contemporary medicine's deep knowledge of mental disorders.As an illustration, speaking of persecutory delusions, he alluded to the classification of "valid" and "invalid" brains by German psychiatrist Schüle, and argued that a degenerate patient could perfectly well be cured: "it can occur that unhealthy brains, attacked by any form of psychosis, have recovered; and vice versa, that brains in a healthy condition, with no trace of insanity, have become incurable on the first attack of madness" (Sanz y Gómez, 1894, p.70).
Sanz y Gómez promoted in-home care for patients as a better method.He defended the phrenopathist's role in balancing the application of pharmacological, hygienic and therapeutic approaches, which included the choice of a room, clothes, physical exercise, number of hours of sleep etc., which, when left to an inexpert person, rendered a cure impossible (Sanz y Gómez, 1893, p.744).In addition, he strongly criticized the isolation of patients as a morally harmful treatment that was counter-productive for the patient's improvement, to such an extent that he believed it was the cause of bad outcomes in many cases.Thus, the curably insane person, on being confined to an asylum, "ends up becoming aboulic, cowed, intimidated … This is one of the reasons, among others, why in asylums patients so often end up with chronic systematized delusions, catatonic states and chronic dementias" (p.759).On this issue, José María Escuder (1895), who was also a disciple of Esquerdo's at Carabanchel Alto, fiercely attacked the asylum's ability to provide a cure in a book he wrote.He based this view on various arguments: firstly, the oft-cited lack of resources on the part of the provincial governments, thanks to which the centers lacked the necessary personnel to care properly and differentially for mental patients according to their pathologies.He also felt that being admitted to an asylum was harmful from the emotional point of view: "interning a man in an asylum always involves something humiliating and painful; the patient, however limited his lucidity, is aware that he has passed into another world, that he no longer forms part of rational mankind, and that, even though it is a hospital, is more deeply depressing than death" (Escuder, 1895, p.314).In an article in which he commented on the lamentable conditions at the Valencia asylum, which was very badly run at the time (Heinemann, 2006), he defended the efficacy of private treatment: "it is not proven that every madman needs isolation from his family; I have carried out quite a few cures without the patient having to abandon his home, children and wife.If possible, that is the best form of care, because paid nurses can never be compared to those who are connected to the sufferer by bonds of blood and affection" (Escuder, 1896, p.751).While he argued that over 50% of the types of madness could be cured, he stated that the only way to do so was through individualized care, developed with the help of a phrenopathist: "the poor will be admitted to those asylums, but the rich, who can afford the luxury of being cared for by a competent doctor, will flee that confusing environment" (Escuder, 1895, p.317).He proposed that the asylum population should consist of incurable patients.
Vicente Ots y Esquerdo, mentioned earlier, was the director of the provincial asylum in Vizcaya and later turned to private practice.While in an early article he argued, following his mentor's model, that "in-home treatment … is extremely harmful in almost all prodromal, initial or status phases" (Ots y Esquerdo, 1895, p.6), in other later pieces he presented clinical cases from his practice where he had treated patients at home, with evident success.These stories were explained using rhetorical strategies in which he justifies his status as an expert of proven skill.In a case of hysterical madness, he claimed, "I do not in any way propose to record a personal therapeutic success… [This] is commonplace for those of us who have earned a profusion of worn-out gray hairs in the exercise of our profession" (Ots y Esquerdo, 1902a, p.365).His treatment of the case was based on pharmacotherapy which, although it was no different from the one traditionally used, he described as specific.Thus, through the use of sedative medication, tonics, hypnosis and hysterotherapy, the patient in this case recovered from her delusional convictions, stopped hallucinating and completely recovered her health.In a case of neurasthenic madness, his approach was similar.The author described the major symptomatic manifestations suffered by the patient as loss of vital tone and isolated episodes of agitation, and he treated these also with specific drugs: sodium nitrite, potassium bromide and laxatives, which led to a cure (Ots y Esquerdo, 1903a).
For Ots y Esquerdo, Kraepelin's theories on the irreversible nature of madness set up a pessimistic model that was incompatible with the argument that insanity could be cured.Thus, he violently rejected the new nosological divisions of the German psychiatrist, whom he accused of sowing confusion and creating unjustified pessimism about treatment: "nor do we feel that the denomination of dementia is admissible, given the clinical consideration of cerebral ruin attached to the term and the necessary conclusion that the prognosis is incurable, a circumstance that is not seen in all the adolescents affected with this syndrome" (Ots y Esquerdo, 1902b, p.333).He recalled the case of a patient with this diagnosis who was cured, completely reintegrated psychologically and able to finish his engineering degree.In a later article, he criticized Kraepelin's criteria for incurability with the comment that "the same curability of this psychopathology, of which there have been undisputable cases in my practice… openly contradicts the generic denomination of dementia" (Ots y Esquerdo, 1903b, p.401).

Final considerations
At the beginning of the twentieth century there were changes in the discourse about curability in Spanish mental health care, and the efficacy of the moral treatment was viewed with more pessimism.However, phrenopathists could not stop defending the therapeutic efficacy of their specialty, since they did not have too many other ways of generating a professional discourse that would publicly promote the usefulness of psychiatry in another area, and furthermore, no alternative therapeutic methods had been developed to take the place of the asylum.Meanwhile, psychiatrists involved in private practice harshly criticized the moral treatment, and argued for a markedly optimistic discourse on curability in psychiatry, one that fit their own needs.
Phrenopathists' support for the degenerationist model did not prevent them from continuing to uphold discourses on the therapeutic efficacy of psychiatry.In the early decades of the twentieth century, Kraepelinian nosological ideas were discussed, and phrenopathists regarded them with some ambivalence, among other reasons because of Kraepelin's pessimism regarding treatment.