IV RECOVERIES IN DEMENTIA PRÆCOX. BY WILLIAM W. COLES, M.D. Perhaps no problem of clinical psychiatry is exciting more interest at the present time than that of the prognosis in dementia præcox. Certainly no questions are more frequently put to the physicians in our various hospitals by anxious relatives than those relating to the outcome of this form of mental disease. Affecting as it generally does the younger members of the family, those in whom parental hopes are centered and who often have, until a comparatively short time before the hospital admission, given much promise for the future, the anxiety to get some definite statement, if possible one that may be encouraging, is by no means incomprehensible. And still less so when the course of these cases is considered, marked as it often is by what appears to the family as a sudden onset due to some trivial incident of daily life, to say nothing of the favorable progress which frequently characterizes the earlier months of their hospital residence. Basing an opinion upon the statements of the earlier European authorities as well as on observations made during the first years. subsequent to the recognition of this form of insanity in this country, the response to these inquiries has often been favorable. Further experience, however, soon developed a conservative attitude which led the physician to place at least a somewhat different interpretation upon clinical features which are common to almost all psychoses. "Possible recovery with defect" came to be the standard formula with which these anxieties were met, while in the minds of many psychiatrists the rapid deterioration. following periods of temporary improvement as well as the profound disturbances characteristic of the more frankly unfavorable types, overshadowed the picture and "once a dementia præcox always a dementia præcox" came to be a commonly heard phrase in the privacy of the office, if not in the reception room; but careful students of psychiatry have not been willing to accept either the relative optimism of the earlier view nor the epigrammatic pessimism of the later, without statistical data, and the present paper is offered as a contribution to this phase of the subject. We have taken our material from a group of cases admitted to the Westborough State Hospital during the years 1904, 1905 and 1906, believing that the intervening six to eight years should give us a reasonable perspective for our observations, an opportunity to determine the validity of our opinion of the patient's 120 men. condition at the time of discharge. Three hundred and two cases subsequently diagnosed as dementia præcox were admitted to the Hospital during the above mentioned period, 182 women and Of this number 124, 75 women and 49 men, have been constant residents here, have been transferred to some other hospital in the State or are boarded out in private families under direct observation of the State Board of Insanity. The course of the psychosis in those resident in this institution has been progressive, and the report concerning those transferred to other State hospitals or boarded out is no more favorable. Thirty-two, 23 women and 9 men, died in this or another hospital. Thirtyfour, 16 women and 18 men, were deported either by the United States Immigration Commission to their native countries or by the State Board of Insanity to other States. None of these cases were classed as recovered at the time of their discharge from the hospital. Five men made good their escape from the institution and under the names they bore here have not been admitted to any other hospitals in the State; two of these having taken up their residence, one in a Southern and another in a Western city, have written letters to us which are part of our records and fit in well with the psychosis as observed during their hospital confinement. Seventy-two, 45 women and 27 men, were permitted to leave the hospital in the care of friends but were not considered as recovered at the time of their discharge and for this reason have been eliminated from special consideration in the present paper. However, the writer is familiar with the subsequent history of a fair percentage who have been able to remain at home but have shown a degree of indifference or instability characteristic of the milder cases of dementia præcox. There remain, then, as the subjects for the present study 35 cases, 23 women and 12 men. Of this number one man was accidentally drowned a few weeks after his discharge from the hospital and his case can be eliminated. Another man having had a previous admission to the hospital was removed as a recovered case, but after a relatively short remission was recommitted and has for the past three years shown marked indifference and untidiness, features which were not observed to any extent during his former hospital residence, though the diagnosis of dementia præcox had not been questioned. Three cases, two women and one man, were subsequently readmitted to the hospital and again discharged recovered, the diagnosis in each having been changed at the second admission to manic depressive insanity. For obvious reasons those cases can be left out of our discussion. An attempt has been made to obtain data as to the subsequent histories of the remaining thirty cases. The difficulties are of course apparent. Several of our letters of inquiry met with no response whatever, owing probably to indifference on the part of relatives or friends or even, possibly, to suspicion of the motive prompting the inquiry, not unnatural among the ignorant. As many more we were unable to reach owing to changes of residence. We have been able to communicate directly with twelve cases, five by personal interviews and seven by letter. CASE I. No. 6023. Admitted June 1, 1904, age 21. Family history negative, but both parents were of mixed white and negro blood. Healthy until the present illness, free from any eccentricities, a graduate at 17 of a city high school and since then employed as a milliner. She has worked very hard in the shop and done sewing for herself at home in the evening beside studying music. Six months ago she suffered a nervous breakdown and had to give up her work, but had returned to it though not entirely well, and her work worried her. The death of her mother at this time she took greatly to heart. Menstruation had ceased for three or four months. A week before admission she suddenly developed the idea that she had committed some crime. and was to be arrested. She said that she had disgraced her family, made repeated attempts to suicide and was excited, restless and emotional. She masturbated excessively. After her admission the excitement continued, resistiveness was a feature, and she made attempts to suicide. Delusions with hallucinations persisted. To relieve the apparent intense sexual excitement orificial work was done, but there was no improvement until December 1904, when she commenced to interest herself in her surroundings. She improved slowly but made frequent complaints of pain in the left ovarian region. After careful consideration and surgical consultation a vaginal hysterectomy was performed, the left ovary being found cystic and the tube inflamed. She made rapid progress after recovery from the operation, and November 27, 1905, was discharged, showing good insight and her normal ambition for work. Her brother reports that she has continued to improve at home and gained in weight. For the past four years she has been in business for herself as a milliner and dressmaker and has done well. CASE II. No. 6095. Admitted July 29, 1904, age 24, a native of Austria, five years in the United States. Mother insane for a year in middle life, but recovered. Maternal uncle died of apoplexy. A tailor by trade, he has worked steadily all the time since coming to this country, but changed his place of employment three or four times. For the past two years, has worked very hard and in the same place. Became tired out and decided to take a rest, in the early part of July going to a Y. M. C. A. camp in northern New England. Remained there but one week, saying that he could not rest because of the noise. Returned home and gave expression to persecutory ideas and fantastic delusions dealing with religion. He was irritable and confused. When admitted he was not confused but excited, irritable and occupied with his persecutory delusions. He showed ideas of reference. After a short period of improvement, during which partial insight developed, he again became excited, and these fluctuations in his conditions persisted for six months. At times he was untidy and negativistic. During the middle of January, 1905, he was interested in regular employment and made a steady gain. He left the hospital for a trial visit March. I, 1905, and renewed his furlough April 29, having worked steadily at his trade and appearing in a normal condition. He was finally discharged April 30, 1905. Following his discharge he worked for nine months for his brother and has since been in business for himself, doing well. CASE III. No. 6265. Admitted December 18, 1904, age 18. Hereditary tendency denied. Has always been a source of anxiety to his family, could not learn in school and though a fair worker was very unstable and often ran away from home. He was very untruthful, and stole money from his family and employers. He was twice at the Lyman Reform School, and because of excitement, violence and threats of suicide during his last residence there was committed to Westborough. When admitted he showed no defect of memory or orientation and was not especially excited. He claimed that he heard voices which threatened him with death. His range of thought was limited and judgment very poor. After the first day he never referred to hallucinations except on one occasion following a short period of irritability, a frequent symptom if he was not allowed his own way. He made his escape once from the hospital but was returned after two months, during which he had worked a part of the time. He claimed to be subject to what he called "fainting fits," but they never manifested themselves during his hospital residence. From February 1906 to the time of his discharge, March 1, 1907, he was fairly stable but always showed the same limited range of ideas and was dependent on others to a marked degree, having some new request to make of the physician at every opportunity. Certain facial mannerisms developed during this period. He has visited the institution several times since his discharge, and though he has managed to keep out of trouble and has worked more steadily than formerly he shows the same general characteristics. CASE IV. No. 6299. Admitted January 13, 1905, age 25. Father alcoholic and a patient at Danvers before his death. Many of the paternal grandmother's people were tubercular. After passing the period of susceptibility to the children's diseases he suffered from nasal catarrh and had an attack of typhoid in 1900. Was always very self-conscious and inclined to keep by himself. He gradually grew a little deaf, and for two years complained of ringing in his ears. He graduated from the Massachusetts Institute of Technology in 1901, in the department of Electrical Engineering, and has been employed in the West in the practice of his profession. For a year he has not had his usual ambition for work and has seemed dull and indifferent, as shown by his letters from the West as well as in his attitude after coming home in November 1904. At that time he was depressed, talked of himself as a failure and was suicidal; was at a private sanatarium for a short time before coming to Westborough. When admitted was much depressed and very nervous, constantly sniffling and biting his nails. Talked of his life as a failure and of his hopeless future. Orientation and grasp on his surroundings were good and he had partial insight. No hallucinations. A period of marked apathy with mutism and untidiness supervened immediately following admission and he tried to escape from the ward. In the latter part of February frank cataleptic manifestations with cerea flexibilitas developed, persisting until the middle of May with marked loss in weight. At that time he again began to talk, showed evidence of active hallucinations of hearing and threatened suicide persistently. During the summer and fall he showed a little improvement, but in December 1905 he passed into a state of acute excitement, was very noisy and incoherent, talking in a silly manner and showing marked restless He was utterly careless as to his appearance. During 1907 the excitement gradually subsided and he became very apathetic, though hallucinations persisted. In November of that year he passed through an attack of acute rheumatism, during which there commenced a definite improvement in his mental state. January 28, 1908, he gave a detailed account of the experiences of his psychosis and the delusions to which he had given expression, showing good insight. He could recall nothing of the cataleptic period. He was anxious to leave the hospital but was willing to leave the matter to the discretion of the physicians. His subsequent recovery was uneventful, and June 19, 1908, he was discharged. His mother states that he has been well since |