CHAPTER VI.

COURSE AND TERMINATIONS.

THE beginnings of insanity are often insidious; especially is this the case with forms that take from the start a chronic course. The prodromata are very commonly overlooked in acute cases, and it often happens that only a retrospective study of the history of the case very carefully made will give any idea of the conditions that preceded the attack. We may say, in a general way, that the beginnings of insanity vary, and divide into two great classes of cases those in which there is a pronounced neuropathic or psychopathic predisposition, and those in which the mental disease occurs in a normally or nearly normally constituted individual. In the first class the outbreak may be extremely sudden and have but little in the way of antecedents. The patient may be apparently in perfect health and without anything in his or her symptoms that leads to any anticipation of the outbreak. Generally, however, there are a few prodromata-some change in disposition, an unusual irritability or excitability, or some slight changes in manner or disposition that are remembered by the closest friends after the onset of the disorder. There are frequently, also, disturbance of sleep, sometimes amounting to decided insomnia, and a constipated. condition of the bowels, with more or less digestive disorder. Patients who have suffered from acute attacks, and especially more than one, coming on suddenly while engaged in their ordinary occupations, have stated that if they could avoid constipation and sleeplessness, they could also avoid the attacks. Of

course, it generally happens that the causes of these conditions of which they complain lie still further back, and are ignored by them.

In cases where there is no hereditary or other predisposition to insanity, and where it occurs from known or suspected etiologic conditions of illness, overwork, mental trouble, etc., there is very commonly a preliminary period, where, besides the disorders of digestion and sleep, there is a more or less marked depression, some weakness of memory, and other intellectual disturbance that may excite the attention of those about them, and lasting for some days before the outbreak of actual acute insanity. This, in fact, is so common that it has been considered by some authors as a rule, and a prodromal period of depression has been described as the usual thing in cases of acute mania. In periodic insanity, which is usually a degenerative psychosis, the suddenness of the changes and of the onset of the attack is very marked, and the causal factors, immediate or otherwise, may be so slight as to be absolutely undetectable. The patient

may break down at once into a state of acute melancholia, but more commonly there is an exalted condition of intellectual excitement, which may, in many cases, not exceed the normal condition of the individual 'to such an extent as to make those about him consider him actually insane. Many of these people have during the greater period of their lives been considered as simply eccentrics, subject to spells of uncommon vivacity of mind, alternating with those of depression.

In the more chronic forms of insanity the onset is more insidious, as already stated. The patient for a long time develops peculiarities which are at first unnoticed, but gradually begin to be remarked, and are particularly remembered when, by some act, the fullfledged mental disorder reveals itself. In a case of paranoia it may be months or years before the individual

is even suspected of being in any way wrong.

There is

a sort of conflict that sometimes exists between his correct judgment and his disease, and yet he is able to conceal his mental disorder to such an extent that he can go about his daily occupation unsuspected. Sooner or later, however, actions and words betray his condition, though in these cases it often happens that it is difficult. to convince friends and relatives that there is anything wrong. Patients of this class have mingled with their fellows for years, always sources of danger, but with their condition suspected or recognized by but few. In profound organic dementia and in paresis there is generally sufficient change of habits and morals to make the condition recognizable or suspected, at least before it has progressed very far. What difficulties there are in this regard will be noticed more at length in the chapter on diagnosis. In certain cases the attack of insanity may be so transitory that its whole duration covers only a few hours or days. Transitory frenzy, though denied by some authors, is a recognizable and well-established form of mental disease. The pre- and post-epileptic conditions are, of course, so generally associated with the marked symptoms of the neurosis as not to require further remarks here in this regard.

The course of insanity, when it is once fairly established, may be continuous or intermittent. In acute cases, especially of mania, it is apt to be short, though relapses may occur. In certain forms of exhaustional and toxic insanity it is almost self-evident by the physical condition of the patient. Melancholia and depressed and stuporous conditions generally are apt to drag along over a greater length of time, and the changes that occur, excepting in the periodic cases, are apt to be more gradual.

It is customary, or has been so, in many asylums to consider a case that has continued without pronounced steps towards convalescence for a year or more as

chronic, but this is no absolute criterion.

In the most acute forms of mania there is apt to be so much damage done to the brain after a certain period that this tendency to chronicity thus recognized has some basis of reality. Nevertheless, cases have been noted of acute mania lasting for much longer periods than one year, without apparent amelioration, and ending in a condition which might at least be considered as an approximate recovery. In melancholia there is no limit to the time when recovery may take place, though relapses are liable to occur in any form of acute insanity; and this should be especially held in mind, since the majority of cases, at least, of acute mania are based on a degenerate constitution, and may perhaps be considered, with Kraepelin, as forms or phases of periodic insanity. The lucid periods, however, in some of them are so long that, practically speaking, we may consider them as recovered. It is hardly fair to reckon a lucid interval of years in duration as anything else than at least a temporary recovery.

Remissions may occur in many forms of mental disease, and sometimes these may last for considerable periods, even in organic disease, like paresis. They are, in fact, common in this condition, and sometimes last so long as to lead to a suspicion of recovery, though this is generally disappointed sooner or later by a relapse to the former, or a worse, condition. In acute mania there are often short intervals in which the patient seems almost his normal self for a short period. Acute melancholia, not of the periodic type, is more continuous. We recognize a difference between these remissions and the periodic changes of cyclic insanity which occur with more or less regularity, while the others are altogether irregular in their occurrence and duration. It is not rare to see an intercurrent affection -some serious bodily disease, for example-produce a very decided remission of the symptoms, and some

times a complete temporary restoration of the mental function. This is even observed in old chronic cases, though it is rare in such. The same phenomenon has been observed in the very low conditions that precede death. Sometimes moribund patients that may have appeared demented for months or years may, in articulo mortis, show surprising signs of mental clearness, though under the circumstances, it must be remembered, such symptoms impress themselves unduly upon observers and are easily exaggerated.

There may also be a change in the type of insanity, accompanied with decided mental improvement. A silly, demented patient has been known to become suddenly dangerous and violent, while, at the same time, his mental functions seemed greatly improved. Instead of being absolutely irrational, he was logical and consecutive in his talk, and appeared more as a surly, dangerous case than a demented one.

The duration of insanity is naturally variable, but it may be said that there is no limit to it except that of life. This is true in the chronic cases, many of whom live out a long life in a state of mental hebetude or dementia, and it is also the case in certain forms of delusional insanity. Cases that recover generally do so during the first year or eighteen months, but cases of recovery after many years have been often recorded.

Terminations.-The terminations of insanity may be classed as follows: First, recovery; second, recovery with defect, partial recovery, or improvement; third, passage into the chronic condition; fourth, death.

Recovery. Recovery occurs in a certain proportion of cases, which has usually been estimated to be as high as 30% or 35%. It must be remembered, however, that the estimation of recovery largely depends on the point of view and the personal equation of the person making the estimate. In former times some asylum superintendents reported as high as 75, 80, 90, or 100% of