SECTION II. PROGNOSIS. Insanity cannot be said to have a directly fatal tendency, since it not uncommonly happens that persons, labouring under it live to an advanced age, particularly if the form of the disease be mild. I myself have attended a gentleman, who lived upwards of half a century in this state; and there is at present, in Bethlehem Hospital, an old woman, who has been there for nearly sixty years. Nevertheless, it must be allowed that insanity, frequently exercises an indirect influence in abridging the duration of life. The progress of disease in the brain, the action of external agents and moral influences, tend to induce certain diseased states; in particular, paralysis. With regard to the probability of curing the disease, I would observe, that a hasty prognosis is to be avoided, as it is time alone that can enable us to decide. In one respect it were far better to err by giving a favourable, than an unfavourable prognosis. While hope is held out, efforts will be continued, and every attention paid to promote recovery. If hope be denied, the case is inevitably consigned to chance, and there is no probability of recovery left, but from the efforts of nature. It may be said on this subject, with some degree of confidence, that the prognosis is more favourable in early, than in advanced life; although cases commencing after the age of sixty, have recovered. It is more favourable in Mania than in Monomania, especially when the latter is characterised by depression. In partial insanity with depression, we often find chronic disorder of some of the abdominal viscera, coexisting with a diseased state of the brain, and in such cases, therefore, we have very little hope. The patient generally becomes weakened in body, as well as mind, by every succeeding paroxysm, and at last sinks into a state of incurable Dementia, and seldom lives long. Chronic Dementia and Idiocy, may be considered incurable; still, the condition of the patients may be much improved; since many of the latter class even, may, by a sort of education, be made to perform a few rational and useful actions. The chance of recovery is greater on the first, than on subsequent attacks, and the longer the disease has lasted, the less favourable becomes the prognosis; but our endeavours ought never to relax, until the appearance of Dementia is unequivocally established. The probability of cure, is greatest in puerperal insanity; and also in those forms of the disease produced by causes acting suddenly, as intoxication, retention of habitual discharges, or sudden transference of morbid action from other organs. When the state of furious excitement is succeeded by melancholy, and when after a raving paroxysm of considerable length, the patient inclines to be quiet and to sleep, the prospect of cure is very considerable. The more strongly hereditary predisposition is marked, the less probability is there of obtaining a permanent cure. The disease may leave the patient for a time, but the predisposition still existing, he too often suffers a relapse. If the disease, owing to the violence of sympathetic symptoms, assumes the appearance of acute or febrile delirium, and if after the disappearance of these symptoms, and the restoration of bodily health, there be no amelioration in the mental disorder, the prognosis is unfavourable. Insanity attended by the peculiar species of paralysis, to which the name of general palsy of the insane has been given, is in general hopeless. In my practice, I have only met with one patient in whom a cure was effected, after the disease had once unequivocally manifested itself; and even in this case, the symptoms of palsy re-appeared at the end of two years, and the patient ultimately sunk under it. The combination with the ordinary form of palsy (hemiplegia) may also be regarded as most unfavourable. In both these disorders, the nervous system is disorganized to such an extent that the restoration to a sound state, appears almost to be impossible; and, on this account, patients of the above description, are excluded from some of the public hospitals, for the reception of the insane. Of more than 4000 cases of insanity, mentioned by Esquirol, there are only three in which insanity combined with palsy, were cured. In my own practice I have only met with two cases in which a cure took place. In both of these cases, the palsy remained after the disappearance of the mental disease. With regard to the mean time in which a cure of insanity takes place, much diversity of opinion exists. Thus, according to Pinel, the greater number are effected in six months; while another great authority, Esquirol, thinks we may extend it to twelve months; stating that nearly as many have been cured in the second year of the disease, as in the first. In this, however, I do not agree with him; for in my own practice, I have found the greater number of cures to be effected within from three to nine months of the period of the accession of the disease; and that, in recent cases, that the proportion of recoveries within the first six months, is greater than all the rest put together; as will be seen from the following tables. |