the rate of accumulation of pauper cases, we feel confident that 1800 per annum is within the truth. To meet this increase, both the asylums in existence and those in course of erection are undoubtedly inadequate, and, as the necessary result, workhouse pauper inmates must continue to multiply.
If the opinion were accepted that public asylum accommodation should be provided for all the pauper poor, not many more than one-half are at present found to be in possession of it, that is, 17,000 of the 33,000 in the country. Hence it would be required, to more than double the present provision in asylums for pauper lunatics, to give room for all and to meet the rapid annual rate of accumulation.
Chap. IV. – on the curability of insanity
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.”
