Prognosis

In the early part of the nineteenth century, when the care of the insane had passed from the hands of the clergy, penal authorities, and poor-law officials to those of physicians, the hope was widely entertained that the medical treatment which thus became available for the insane would result in high percentages of cures. Thus, in one of the most important documents in the history of psychiatry in this country, a report under date of March 29, 1834, made to the New York state legislature by a special committee, we read: "It is now satisfactorily established that diseases of the mind yield even more readily to medical treatment than those of the body, and that in at least nine-tenths of the cases of insanity the patient may be restored to the full enjoyment of his mental faculties by the early application of judicious medical treatment." To-day not the most sanguine in the psychiatric branch of the medical profession would make such an assertion. The prognosis of psychotic disease is more correctly indicated by the following analysis of the recovery statistics of the Kings Park State Hospital, at Kings Park, New York, for the year ending September 30, 1915.

Two hundred and fourteen cases were discharged during the year as "recovered," making the recovery rate, based on direct admissions, 20.78%. Many of these reported recoveries, however, can be regarded as such only from a non-158 medical point of view; for of these cases 31 were suffering at the time of their discharge from epilepsy, imbecility, constitutional inferiority, or paralysis agitans, having recovered merely from their "insanity," i.e., from acute psychotic manifestations which had led to their commitment; 49 had had one or more previous admissions to institutions and were evidently recurrent cases without likelihood of continued mental health in the future; 13 had recovered from alcoholic psychoses but probably not from the habit of intemperance; and 24 had been classed as constitutionally of inferior or defective make-up and had recovered not, of course, from their inferiority or defectiveness but, like the first mentioned group, merely from acute psychotic manifestations which had led to their commitment.

This leaves but 97 cases which can be said to have recovered in the sense of having shown at the time of their discharge a real freedom from demonstrated psychic abnormality. But if the universal past experience is a trustworthy guide, then it is unfortunately but too sure that a certain proportion even of this remnant will prove sooner or later to be of a recurrent nature; so that it is extremely doubtful if complete and permanent recoveries have occurred in more than 5% of all cases admitted.

It should be added here that the experience of the Kings Park State Hospital is, in this respect, by no means unique; on the contrary, it is but the general experience of psychiatric practice all over the world, as may be judged from the following passage quoted from Kraepelin:l "Only a comparatively small percentage of cases are permanently and completely cured in the strictest sense of the word." This statement, we believe, voices the concensus of competent psychiatric opinion.

It would seem from this that radical dealing with the problems of mental disease must be by way of prevention and not treatment.

1 Kraepelin. Lectures on Clinical Psychiatry. Second edition in English, New York, 1906. P. 2.

Prevalence of Mental Disorders: Are They on the Increase?1 - During the past several decades the number of insane in institutions has been increasing at a faster rate than the general population. Thus, according to the United States census statistics there were, in 1880, 81.6 patients in institutions for the insane per hundred thousand of the general population; in 1910 the number had risen to 204.2. To what extent, if any, does this fact indicate an actual increase in the prevalence of mental disorders in the American population?

There can be no doubt that, at least to some extent, the increase of patients in institutions is due merely to the general improvement in the kind and adequacy of facilities for their care; and if the statistics of various states for any one year are compared with one another, marked differences are found, corresponding to stages of progress in social organization, and altogether analogous to those shown by the entire country in years separated by decades.

Thus, for instance, in 1910 there were in the state of Oklahoma 67 patients in institutions per hundred thousand of the general population, while in the state of Massachusetts there were 344.6; and between these extremes all degrees of transition were presented by the statistics of other states.

It is obvious, therefore, that the number of patients in institutions,' either in the entire country at different times or in different parts of it at any one time, cannot be taken as a correct measure of the prevalence of mental disorders among the people.

For this reason, attempts have been repeatedly made to enumerate the total number of insane persons both in and out of institutions in the various states.2 The resulting data were, however, so manifestly untrustworthy that eventually it became apparent that the difficulties inherent in such an undertaking were greater than, for the present, we can cope with successfully, and such attempts have, accordingly, been given up.

1 A. J. Rosanoff. 7s Insanity on the Increase? Journ. Amer. Med. Ass'n, July 24, 1915.

2 U. S. Census from 1850 to 1890.

Of these difficulties the greatest and, perhaps, the sole insurmountable one is that of formulating such a definition of insanity as to enable enumerators readily and uniformly to distinguish between sane and insane persons, under all conditions.

Furthermore, whoever is familiar with psychiatric clinical material knows that, owing to the nature of things, even if it were possible to formulate a definition and thereby draw a line sharply distinguishing, for practical purposes, sanity from insanity, the line could be thus drawn only in relation to some more or less arbitrary standard of normality.