^∗ A comparison of the death-rate in asylums for the insane, to be of any value, requires a minute inquiry into the various causes of their difference.Google Scholar

The mortality is always greater in those establishments destined specially for recent cases than in asylums proper, for the majority of deaths amongst the insane occur within the first twelve to eighteen months of the malady. This is explained by the fact that the recent and acute cerebral affection may be merely a complication of serious physical disease ; also by the frequent occurrence of mania or of general paralysis in the early stages. The comparative frequency of this latter complication tends, more than any other circumstance, to modify the statistics in different countries and in various institutions. It is this, also, which causes in general a greater (earlier) mortality amongst malee than females. In Bethlehem, where no case of more than a year's standing and no epileptic or paralytic is admitted, and where no case is detained longer than a year, the mortality was 6 to 9 per cent. St. Yon, a general asylum, over 7 per cent. Winnenthal, almost solely devoted to curable cases, in the twenty years from 1834 to 1864,11 to 12 per cent. Siegburg, in the four years from 1846 to 1950,10 to 11 per cent. Sachsenburg, in the ten years from 1840 to 1849, 16 to 17 per cent. Hanwell, 12 per cent. Lenbus (for curable cases), in twenty-four years, 16 per cent. (Martini). The English poorhouses, 27 per cent. The Antignalle, in Lyons, 90 per cent. It would be not only irksome but impracticable to consider here the various circumstances which cause the remarkable differences presented by these superficial quotations. Hitchman (1850) came to the conclusion (from the statistics of Hanwell) that the normal ratio of mortality is tripled in mental disease. (This note is far from accurate.$C. L. R.)Google Scholar

^∗ It is evident that by such improvement is to be understood, not only a state of outward calm, but an essential alteration, comprehending the complete arrest of the farther progress of the disease. It would, for example, be wholly inadmissible to declare that a maniac whose disease had gradually verged into dementia, and who was now, as a consequence, quiet and inoffensive, and could even be kept in private circumstances, was on that account improved. Such a case has, on the contrary, become in reality aggravated, and can only be dismissed from the asylum as no longer curable.Google Scholar

^∗ It may be here permitted to give a few quotations from the statistics of the asylums of Germany. Winnenthal had in twenty years (1834 to 1854) 1424 admissions (888 males, 536 females) ; whereof there were 445 recoveries (260 males, 185 females), equal to 31 per cent. Siegburg, from 1st October, 1846, to 31st December, 1850, 872 patients, 277 recoveries, equal to 31 per cent. Sachsenburg, in ten years (1840 to 1849), 695 admissions, with 213 recoveries, equal to 30 to 31 per cent. From Sonnenstein, during the five years 1846 to 1851, there were dismissed recovered 33 per cent, of those admitted. These results correspond in a remarkable manner with one another, and when Flemming says (‘Ztschr. f. Psych.,’ XV, 1858, p. 8), “It is at the present time satisfactorily demonstrated that, with respect to mental diseases, no statistics exist whereon conclusions may be founded regarding the curability of these diseases or the efficacy of the remedial means employed,” I quite agree with him on the latter point, but I cannot at all endorse his statement regarding the curability of insanity.Google Scholar

^∗ Some observers (Esquirol) were disposed to consider only those cases of recovery as sufficiently certain which were accompanied by a well-marked crisis; others (Jessen, C. G. Neumann, and ourselves) have, upon the whole, very seldom observed such crises. We do not deny that those constitutional changes, which must frequently accompany recovery from such a serious disease, may occasionally be announced by increased quantity or altered quality of the excretions, by the appearance of skin eruptions, &c., and that to a certain extent a favorable interpretation is due to those events when they occur coincidently with mental improvement. These phenomena appear, however, more frequently as results than as causes of the recovery ; very often they are wholly accidental occurrences, and the fact of their frequent complete absence would of itself sufficiently refute the opinion of Esquirol.Google Scholar

^∗ [Dr. Thurnam's estimate is not so favorable. ‘Of 244 persons (he writes) attacked with insanity, under all circumstances as to ape, sex, and form of dis order, and as to proper care during the early stage of the disorder, 131, or 53-6 per cent., recovered from the first attack, duriug which the rest died. And on following the 131 through life, it appears that there was only one third of these, viz., 45, or 18.4 per cent., of the whole, whose recovery was permanent. The remainder experienced one or more subsequent attacks, the majority dying in a state of insanity; so that of the whole number rather more than one fourth only, 65 (45 + 20), or 26.6 per cent., were in a state of mental health at the time of death. In round numbers, then, of 10 persons attacked by insanity, 5 recover and 5 die sooner or later during the attack. Of the 5 who recover, not more than 2 remain well during the rest of their lives; the other 3 sustain subsequent attacks, during which at least 2 of them die. But though the picture is thus an unfavorable one, it is very far from justifying the popular prejudice that insanity is virtually an incurable disease. And the view which it presents is much modifled 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 life.”—C. L. R.]Google Scholar