CHAPTER XIII.

DURATION AND CURABILITY OF MADNESS.

§ 315. WITH the exception of that kind of dementia that occurs at other periods of life than that of old age, mania is the only form of insanity that admits of a cure; and though its duration is various, the probability of this event is almost entirely destroyed within a comparatively short space of time. This is abundantly evident from the statistics of madness that have been published from time to time by the heads of various lunatic establishments. Esquirol concludes, on data furnished by the returns of the principal French and English hospitals, that the absolute number of recoveries from madness is about one in three; and also that the number of recoveries varies in different establishments, from one in four, to one in two or two and a half of the whole number of persons affected. Prichard regards this computation of recoveries as much below what really takes place under favorable circumstances, and the reports of American hospitals confirm the correctness of his opinion. Such, however, is the imperfection of statistics on this subject, that we can speak with but little confidence respecting the proportion of recoveries. We only know that in cases subjected to judicious treatment soon after the attack, recovery takes place in the proportion of six or eight to ten; while in those which have continued a couple of years, there is little prospect of recovery. Pinel, in a memoir presented to the Institute in 1800, was led to conclude from a selection of cases expressly chosen for this purpose, that a greater number of recoveries takes place in the first month than in any succeeding one, and that the mean time of the duration of the dis

1

ease when cured, is between five and six months. Esquirol, however, gives a table of recoveries at the Salpetriêre during ten years, which shows a little longer term to insanity. Out of two thousand and five patients, twelve hundred and twenty-three were cured, viz., six hundred and four during the first year; four hundred and ninety-seven in the second; eighty-six in the third; and forty-one in the seven succeeding years; from which it appears that eleven twelfths of the number of cures is obtained within the first two years; that the mean duration of cases cured is a little short of one year; and that after the third year, the probability of a cure is scarcely more than one in thirty. M. Desportes states, from observations made at the Bicêtre and Salpetriêre, that of the whole number of recoveries in 1822, 1823, and 1824, seven hundred and forty-six took place in the first year, and one hundred and eighteen only from the second to the seventh year.1 § 316. Recovery from insanity generally takes place gradually, though occasionally the disease may suddenly disappear on the occurrence of certain moral or physical impressions. Pinel relates the case of a literary gentleman who, in a paroxysm of suicidal mania resolved to go and jump into the river. On arriving at the bridge, he was attacked by robbers, against whom he defended himself vigorously, beat them off, forgot the purpose of his excursion, and returned home cured. Dr. Rush relates that one of his patients, for whom he had recommended gentle exercise on horseback, was suddenly cured in consequence of the fright experienced from her horse running away in one of her excursions. He was stopped by a gate, and when her attendants came up they found her entirely restored to reason. Several other cases of recovery are related, produced by a similar cause. Esquirol speaks of having cured a girl at once, by the terror she experienced at the sight of the actual cautery which he was about to apply. He also mentions the case of a girl who, after being insane ten years, suddenly ran to her mother's bed, exclaiming, as she embraced her, "Mother,

1 Esquirol, Des mal. ment. i. 94.

mother, I am well." She had become insane in consequence of a suppression of the menses which at last made their appearance on the evening preceding her cure. Prichard states that several instances of sudden cure from the same cause, have occurred in some of the English hospitals. Insanity has been sometimes cured by an attack of fever. A number of maniacs were once cured, in the Pennsylvania hospital, by a malignant fever which appeared in that establishment. Direct appeals to the reasoning power have sometimes been followed by immediate recovery. Pinel relates the case of a watchmaker who became deranged, and believed that he had been guillotined, and that in consequence of the mixing of the heads of other victims, his own had been replaced by another. When the miracle of St. Denis was mentioned, who carried his head under his arm and kissed it as he went, he contended for the possibility of the fact, by appealing to his own case, when one of his companions burst into a loud laugh, saying, "What a fool you are; how could St. Denis kiss his own head? was it with his heel?" The absurdity of the idea struck his mind, and he never after spoke of the misplacement. Dr. Cox speaks of a patient who believed that he was the Holy Ghost. Another asked him, “ Are there two Holy Ghosts? how can you be the Holy Ghost and I be so too?" He appeared surprised, and after pausing awhile said, “But are you the Holy Ghost?" and when the other replied, "Did you not know that I was?" he answered, “I did not know it before; then I cannot be the Holy Ghost." It is probable that in nearly if not quite all these cases of sudden recovery by means of mental impressions, the disease was declining, and that its termination was hastened only by these impressions.

1

§ 317. Partial intellectual mania is said to be cured with much more difficulty than general mania, and the latter is more easily cured when the sequel of some violent cause, than when it has come on gradually from some steadily continued influence. Among the circumstances favorable to

1 Spurzheim on Insanity, 294.

recovery may be mentioned a constitution not greatly debilitated by excesses of any kind, good moral and intellectual education, the absence of hereditary predisposition, and an early medical treatment.

§ 318. The above facts and considerations will furnish the data, on which the physician is to form an opinion relative to the duration and curability of any given case of insanity. While in very many cases incurability is almost certain, and there can be no hesitation in certifying the same, there are none in regard to which we can predict a certain recovery. The utmost we can say in the most favorable cases is, that the patient will probably recover, and the physician cannot be too cautious how he commits his own reputation and the interests and happiness of others by the expression of hasty and positive opinions.1 Idiocy, imbecility, and senile dementia admit neither of cure nor amelioration, and when mania is of more than two years' standing, and especially if other circumstances are not favorable, it may be safely said there is but little hope of cure, but never that the case is beyond all hope. It should be borne in mind that persons, after years of insanity, have sometimes recovered their reason shortly before death.

§ 319. An important feature of insanity in a medicolegal point of view, is its tendency to relapse during convalescence, and to recurrence after being perfectly cured. The general rule is, that a brain which has once been the 'seat of the maniacal action is far more liable to its recurrence, than one which has not. Many recover the full strength and activity of their mental faculties, but the majority, Prichard thinks, are curable only to a certain extent. "They remain," says Esquirol, "in such a state of susceptibility that the slightest causes give rise to relapses, and they only preserve their sanity by continuing to live in a house

1 If proof be required of the propriety of this warning, the reader will find a memorable one, in Wraxall's (Posthumous Memoirs) lively description of the contradictory statements and dogmatic assertions into which the medical attendants of George III. were betrayed by party zeal, and which resulted in the confusion and disgrace of some respectable physicians.

where no mental agitation or inquietude, no unfortunate contingency is likely to fall to their lot, and throw them back to their former state. There are other individuals whose faculties have sustained such a shock, that they are never capable of returning to the sphere which they had held in society. They are perfectly rational, but have not sufficient mental capacity to become again military officers, to conduct commercial affairs, or to fulfil the duties belonging to their appointments." 1 The proportion of cases in which insanity is recurrent, is estimated by writers at from one tenth to one sixth; Esquirol estimates it at one twentieth. In those cases where the mind on recovery regains its usual capability, this disposition to recurrence is by no means so strong, as when it is left in a weak and irritable state, and it diminishes with the length of the interval after the recovery. This feature of insanity should ever be borne in mind by the physician, when required to give his opinion on the propriety of removing the interdiction of an insane person, who is apparently restored to health. He should seriously consider the risk that he runs, by entering again on the busy scenes of life, and enduring the anxiety and excitement attendant on the management of his affairs, of renewing that cerebral irritation which the quiet and repose of seclusion have temporarily subdued. In criminal cases, also, it should lead to a thorough and candid investigation of the plea of insanity urged in defence of those who have previously suffered from it, and it should be satisfactorily settled whether or not the circumstances attending the criminal act were likely to reproduce that pathological condition on which insanity depends. If it should prove that they were of that nature, and that the individual had but recently recovered from an attack of insanity, then it would indicate a confidence that springs from some other source than a just appreciation of the phenomenon of insanity under consideration, to presume, nevertheless, the continuance of mental soundness and, consequently, of moral responsibility.

1 Des maladies mentales, i. 96.