An inquiry into the curability of insanity forms a natural pendent to that
concerning the provision required for the insane, and is at the same time
a fitting prelude to an investigation of the insufficiency and defects of
the present organization of asylums: for it is important to satisfy
ourselves as to what extent we may hope to serve the insane, by placing
them under the most advantageous circumstances for treatment, before
incurring the large expenditure for securing them.
Now it may be most confidently stated that insanity is a very curable
disorder, if only it be brought early under treatment. American physicians
go so far as to assert, that it is curable in the proportion of 90 per
cent., and appeal to their asylum statistics to establish the assertion.
The Lunacy Commission of the State of Massachusetts (_op. cit._ p. 69)
thus write:--"In recent cases the recoveries amount to the proportion of
75 to 90 per cent. of all that are submitted to the restorative process.
Yet it is an equally well-established fact, that these disorders of the
brain tend to fix themselves permanently in the organization, and that
they become more and more difficult to be removed with the lapse of time.
Although three-fourths to nine-tenths may be healed if taken within a year
after the first manifestation of the disorder, yet if this measure be
delayed another year, and the diseases are from one to two years'
standing, the cures would probably be less than one-half of that
proportion, even with the same restorative means; another and a third year
added to the disease diminishes the prospect of cure, and in a still
greater ratio than the second; and a fourth still more. The fifth reduces
it so low, as to seem to be nothing."
Dr. Kirkbride, Physician to the Pennsylvania Hospital for the Insane, in
his book "On the Construction and Organization of Hospitals for the
Insane," says (p. 2):--"Of recent cases of insanity, properly treated,
between 80 and 90 per cent. recover. Of those neglected or improperly
managed, very few get well."
This is certainly a very flattering estimate, and, inasmuch as it is
founded on experience, cannot fairly be questioned. However, before
comparing it with the results arrived at in this country, there are some
circumstances which call for remark. In the first place, American public
asylums are not branded with the appellation 'pauper,' they are called
'State Asylums,' and every facility is offered for the admission of cases,
and particularly of recent ones, whatever their previous civil condition.
Again, there is not in the United States the feeling of false pride, of
imaginary family dishonour or discredit, to the same extent which is
observed in this country, when it pleases Providence to visit a relative
with mental derangement,--to oppose the transmission to a place of
treatment. From these two causes it happens that in America the insane
ordinarily receive earlier attention than in this country. Lastly, the
United States' institutions, by being more accessible, admit a certain
proportion of cases of temporary delirium, the consequence of the abuse of
alcoholic drinks, of overwrought brain and general excitement,--causes
more active in that comparatively new, changing, and rapidly-developing
country than in ours. But such cases, which for the most part get well, do
not find their way into the asylums of this kingdom. Such are some of the
circumstances influencing favourably the ratio of cures in America, which
need be remembered when comparing it with that which is attained in our
own land.
The proportion of recoveries above stated, is calculated upon cases of
less than a year's duration. Let us see what can be effected in England
under conditions as similar as practicable, though not equally
advantageous. The most satisfactory results we can point to are those
obtained at St. Luke's Hospital, London, where the cures have averaged 62
per cent. upon the admissions during the last ten years. At this and
likewise at Bethlehem Hospital, the rules require that the disorder be not
of more than one year's duration at the time of application for admission,
and that it be not complicated with epilepsy or paralysis, maladies which
so seriously affect its curability. Such are the conditions favourable to
a high rate of recoveries enforced by rule. On the other hand, there are
at St. Luke's not a few circumstances in operation prejudicial to the
largest amount of success possible. Its locality is objectionable, its
general construction unfavourable, its grounds for exercise and amusement
very deficient, and the means of employment few. But apart from these
disadvantages, so prejudicial to its utility and efficiency, there are
other causes to explain its ratio of success being less than that
estimated by our American brethren to be practicable. Though the rule
excludes patients the benefit of the hospital if their disease be of more
than a year's duration, yet from the great difficulties attending in many
cases the inquiry respecting the first appearance of the insanity; its
sometimes insidious approach; the defect of observation, or the ignorance,
and sometimes the misrepresentations of friends, resorted to in order to
ensure success in their application to the charity, older cases gain
admission. Again, of those admitted in any year, there are always several
whose disorder is known to be of nine, ten, or eleven months' duration,
and at least a fourth in whom it is of six months' date and upwards.
Further, although the rules exclude epileptics and paralytics, yet at
times the history of fits is withheld by the patients' friends, or the
fits are conceived to be of a different character, or the paralysis is so
little developed as not to be very recognizable; and as in all ambiguous
cases,--whether it be the duration or the complication of the mental
disorder which is in doubt, the Committee of the Hospital give the benefit
of the doubt to the patient,--the consequence is, that several such
unfavourable cases are received annually. On referring to the statistical
tables of the institution, these "unfit" admissions are found to amount to
10 per cent.
We have thought these details desirable, on the one hand, to account for
the difference in the ratio of cures attained in St. Luke's compared with
that fixed by American writers; and on the other, to show that though the
rate of recoveries at that London Hospital is highly gratifying, it might
be rendered yet more so if certain impediments to success were removed,
and that similar benefits could be realized elsewhere if due provision
were made for the early and efficient treatment of the malady.
Were we at all singular in the assertion of the curability of insanity, we
should endeavour to establish it by an appeal to the statistics of
recoveries among recent cases in the different English asylums; but
instead of advancing a novel opinion, we are only bearing witness to a
well-recognized fact substantiated by general experience. This being so,
it would be fruitless to occupy time in quoting many illustrations from
Asylum Reports: one will answer our purpose.
At the Derby County Asylum, under the charge of Dr. Hitchman, a high rate
of cures has been reached. In the Third Report that able physician writes
(p. 5),--"It cannot be too often repeated, that the date of the patient's
illness at the time of admission is the chief circumstance which
determines whether four patients in a hundred, or seventy patients in a
hundred, shall be discharged cured. Of the 151 cases which have been
admitted into the asylum during the past year, eleven only have been
received within a week of the onset of their malady; of these eleven, ten
have been discharged cured,--the other has been but a short time under
treatment." In his Sixth Report (1857, p. 22), the same gentleman
observes,--"The cures during the past year have reached 60 per cent. upon
the admissions; but the most gratifying fact has been, that of twenty
patients, unafflicted with general paralysis, who were admitted within one
month of the primary attack of their maladies, sixteen have left the
asylum cured,--three are convalescent, and will probably be discharged at
the next meeting of the Committee, and the other one was in the last stage
of pulmonary consumption when she came to the asylum, and died in three
weeks after her admission."
After this review of what may be effected in restoring the subjects of
mental disorder to reason and society, to their homes and occupations, by
means of early treatment, it is discouraging to turn to the average result
of recoveries on admissions obtained in our County Asylums at large. This
average may be taken at 35 per cent., and therefore there will remain of
every 100 patients admitted, sixty-five, or, after deducting 10 per cent.
of deaths, fifty-five at the end of the year. This number, fifty-five,
might fairly be taken to represent the annual per centage of accumulation
of the insane in asylums, were the data employed sufficient and
satisfactory. But so far as we have yet examined the point, this
proportion is larger than a calculation made over a series of years, and
may be approximatively stated at 35 per cent. on the admissions.
How great would be the gain, alike to the poor lunatic and to those
chargeable with his maintenance, could this rapid rate of accumulation be
diminished, by raising that of recoveries, or, what is tantamount to it,
by securing to the insane prompt and efficient care and treatment! How
does it happen that this desideratum is not accomplished by the asylums in
existence? what are the impediments to success discoverable in their
organization and management, or in the history of their inmates prior to
admission? and what can be done to remedy discovered defects, and to
secure the insane the best chances of recovery? Such are some of the
questions to be next discussed.
CHAP. V.--ON THE CAUSES DIMINISHING THE CURABILITY OF INSANITY, AND
INVOLVING THE MULTIPLICATION OF CHRONIC LUNATICS.
In the preliminary chapters on the number and increase of the insane in
this country, we limited ourselves to determine what that number and that
increase were, and entered into no disquisition respecting the causes
which have operated in filling our asylums with so many thousands of
chronic and almost necessarily incurable patients. Nor shall we now
attempt an investigation of them generally, for this has been well done by
others, and particularly by the Lunacy Commissioners in their Ninth
Report, 1855; but shall restrict ourselves to intimate that the increase
of our lunatic population, mainly by accumulation, is due to neglect in
past years; to the alteration of the laws requiring the erection of County
Asylums for pauper lunatics generally; to the collection and discovery of
cases aforetime unthought of and unknown; to the extension of the
knowledge of the characters and requirements of the insane both among
professional men and the public; and, lastly, to the advantages themselves
of asylum accommodation which tend to prolong the lives of the inmates.
Such are among the principal causes of the astounding increase in the
number of the insane of late years, relatively to the population of the
country, some of which fortunately will in course of time be less
productive. Those, however, which we now desire to investigate, are such
as directly affect the curability of insanity, either by depriving its
victims of early and efficient treatment, or by lessening the efficiency
and usefulness of the public asylums.
The history of an insane patient is clearly divisible into three portions:
1st, that before admission into an asylum; 2nd, that of his residence in
an asylum; and 3rd, of that after his discharge from it. The last division
we have at present nothing to do with; and with reference to the causes
influencing his curability, these group themselves under two heads
parallel to the first two divisions of the patient's history; viz. 1,
those in operation external to, and 2, those prevailing in, asylums.