The detection of simulation is more difficult, especially as the insane sometimes feign insanity for a purpose, or, on the other hand, accuse themselves of wrong acts which they never committed. In general, it may be said that sane persons pretending to be insane very much overdo their part, do not make their symptoms conform to any recognized type of disease, and have a strong motive for their deception, as well as for the act for which they wish to be considered irresponsible. Their insanity first appears after the deed; they are exhausted by their efforts to seem mad, and appear quite sane if watched when they think that they are unobserved. A crime performed without accomplices, with no plan or a silly one for escape, and with no sane motive, is usually itself evidence of insanity. On the other hand, people partly demented by chronic insanity often commit crimes with all the method and motive of the criminal. In not a few cases, especially when the fact or not of impaired intellect cannot be decided by comparison with a previous condition, the question of insanity, or at least of responsibility, will be beyond human wisdom. A correct diagnosis can, of course, not be made without a familiarity with the various forms of mental disease; and insanity is now so well understood that a sufficient examination of an insane person should develop the clinical history of some known type of disease in nearly every case.
Little has been said of the physical evidences of insanity, because there is little to say. Conditions of mental torpor, depression, and excitement are associated with the physical manifestations which we would naturally expect in those mental states. Coarse brain disease with insanity or without may have identical physical signs; paralytic dementia is the only disease in which corporeal indications really assist in forming a diagnosis.
A family predisposition to mental disease does not materially affect the question of fact whether a given individual is insane or not, except that in a doubtful case it adds to the probability of insanity, and is thus far a factor of importance as corroborating other evidences of an unsound mind.
PROGNOSIS.—The prognosis in insanity depends first upon the type of disease, mania, melancholia, and some forms attended with confusion and stupor being the most curable; the forms attended with systematized delusions or with periodicity which is not dependent upon menstruation, folie circulaire, and moral insanity rarely so, and the organic brain diseases, congenital insanity, and confirmed primary delusional insanity (monomania) hopeless. The acute forms are far more curable than those of a subacute type: 60 per cent. of the cures in insanity occur in the first half year of treatment, 25 per cent. in the second half, and 2.5 per cent. in the second year, roughly speaking. In chronic cases a reported cure is most commonly only a remission, and after several years of existence insanity is generally incurable, although rare cases of cure in mania have been reported after even from six to fourteen years of treatment, and in melancholia after twelve years. So long as there is no permanent dementia and there are distinct intervals of mental clearness, no matter how short or how far apart, there is hope of final recovery in the curable mental diseases.
People of sound families, with insanity of an acute type arising from physical causes, often make such speedy and complete recovery as to justify their subsequent marrying if they wish, while those of unstable nervous organization recover more slowly and oftener relapse. Insanity from so-called moral causes, too, is of more unfavorable outlook than if from the physical causes, if we exclude organic brain disease. A person with good physical education, excellent mental training, and self-control is more likely to get well than one with a vicious bringing up. The ages of maturity and middle years are most favorable to complete recovery. In women there are more first cures and more relapses, according to Krafft-Ebing. In general, the mortality of the insane in asylums is about four times that of the sane of all ages, or approximately six times that of the sane at the ages when insanity prevails.
Prolonged stupor, profound incoherence, loss of memory, and moral debasement are unfavorable symptoms, unless quite acute, of short duration, or occurring after the rapid subsidence of acute symptoms. Hallucinations of hearing, and to a less extent of sight, impulses to violence, and especially systematized delusions, are grave indications. Paralysis, epilepsy, and convulsions usually mean chronicity or death. Extensive disease of the heart, kidneys, or lungs, confirmed dyspepsia, especially of alcoholic origin, and a previous history of syphilis, seriously affect the prospects of recovery. If there is actual cause for self-accusation, if the knowledge of wrong-doing is added to the morbid mental state, the period of convalescence is apt to be much retarded, or even recovery is prevented, by the difficulty of establishing a healthy reaction. Even an irresponsible act is often magnified into so depressing an influence as to prevent restoration to health, as in the case of those who have injured or killed members of their family.
Of 9689 persons admitted into the Worcester Insane Asylum8 during fifty years ending September, 1881, of whom 1083 had been in other asylums, 35.49 per cent. were discharged well, 26.61 per cent. improved, 17.71 per cent. not improved, 0.5 per cent. not insane, and 14.85 per cent. died. Of those discharged, 25.41 per cent. were readmitted, and of 798 discharged recovered, with regard to whom inquiries were made, 156 were reported well at the time of replying, 197 as having died sane, 30 committed suicide, 162 relapsed and died, 94 relapsed and were alive, 30 were in hospitals or almshouses insane, and of 129 no information was got. Out of 798, there were 316, or 39.6 per cent., known to have become insane again or to have committed suicide. Of 1966 second admissions, 668 recovered; of 607 third, 263; of 261 fourth, 119; of 132 fifth, 70; of 70 sixth, 42; of 48 seventh, 30; of 37 eighth, 21; of 30 ninth, 19; of 26 tenth, 15; of 23 eleventh, 11; of 18 twelfth, 11; of 15 thirteenth, 10; of 12 fourteenth, 8; of 8 fifteenth, 5; of 4 sixteenth and seventeenth, 3; of 4 eighteenth, 2; of 2 nineteenth, 1, who was admitted and discharged well twenty-three times.
8 Forty-ninth Annual Report, including tables by John G. Park, Medical Superintendent.
Thurnam's statistics, that one-half of the recent cases of insanity treated in asylums recover, and that of the recovered only two-fifths remain so, receive constant confirmation. There is a considerable proportion of the inmates of asylums whose brain-condition is so unstable that they come in and go out frequently. Their brains are unstable, too, in the little affairs of life, and many of the nominally cured remain comfortable only by being shielded from sources of physical wear and mental worry. It is impossible to get statistics of the curability of mental diseases properly treated outside of asylums, but the results would probably be more favorable than those just quoted, partly from the greater chances of cure in the mild cases and in those acute cases which can be kept at home, or at least do not require hospital treatment.
It is difficult to form an opinion as to the probability of subsequent attacks in those who have recovered from any of the curable forms of mental disease. The same constitution, of course, remains as that which predisposed the individual to the first attack, and no one can look far enough into the future to predict the influences which will be brought to bear upon any given person for a considerable period of time. If they are favorable for preserving mental health, the chances of escaping mental disorder in the future are very much greater than if the occupation which must be pursued and the life which must be led predispose to bodily exhaustion, anxiety, and brain-worry. If the disease first appeared under slight exciting causes, it will not often be possible to avoid similar conditions again, and some forms of insanity are characterized by relapses and recurrent attacks.