to the recovery of the insane. If this is true, it will militate against the value of many of the statistics which have been collected.

Esquirol asserts that the number of recoveries from insanity is one in three. Prichard, on the other hand, imagines that the computation of recoveries is much too low; and Dr. Thurnum* says, "As regards the recoveries established during any considerable period-say twenty years—a proportion of much less than 40 per cent. of the admissions is, under ordinary circumstances, to be regarded as a low proportion, and one much exceeding 45 per cent. as a high proportion." The many sources of fallacy scarcely require to be pointed out. Those who have a high opinion of figures may retain their respect for them. It is, however, certain that in cases where the disease is not of long standing, treatment can be much more efficaciously applied than in those where it has existed for some time. The analogy of all diseases proves this. There are pathological habits just as there are physiological habits. Dr. Burrowes states the proportion of recent cases cured under his care to be ninety-one in one hundred. This is proved indirectly by the fact that the most favorable age for the cure of the disease is not only the youth of the disease, but the youth of the individual affected. The probability of recovery in middle life is very small in comparison with that which exists in relation to the insanity of early life. And it has been said that recovery almost never takes place after the age of fifty. Dr. Boyd has shown by his tables that 86 per cent. of males, and 92 per cent. of females, attacked with mania under twenty years of age, recovered at the Somerset Asylum during his management.

With regard to prognosis generally, it may be said that, while statistics prove that insanity does diminish the mean duration of life, yet it is not in most cases a disease directly fatal or even dangerous to life. General paralysis does, however, progress through its weird seasons to a fatal issue. Death almost invariably occurs within two years from the commencement of this disease. Some of the acute forms of insanity prove fatal by producing exhaustion, or death may, unless care is taken, follow persistent refusal of food. Another most important point to be marked in connection with prognosis is that, in many phases of this disease, there exists a strong desire to commit suicide.

With regard to recovery, it may be said with truth that it generally takes place slowly and gradually; but that occasionally some sudden moral or physical impression has the effect of removing the morbid beliefs, and the man sits clothed and in his right mind, who only an hour or two since was mad. There are many cases of instant cure related in books on insanity.* After what has been said concerning the causes of insanity, it need scarcely be remarked that, in addition to the circumstances above alluded to, which predispose to sanity besides the youth of the individual and the recence of the disease, an early recovery is to be hoped for in those cases where the constitution is good, where there has been no excess of any kind, where the education of the individual has been good, which not only means good, per se, but which includes good in its relation to the faculties of the individual. The absence of hereditary tendency will of course give the individual more chance of early recovery from insanity, if the insanity is of a kind admitting of cure. When this is the case, when the disease is capable of removal by treatment, it is very difficult to say. We know, however, that idiocy, imbecility, and senile dementia, admit neither of cure nor of amelioration. And until very recent times general paralysis was regarded as not only incurable, but necessarily fatal in a certain time. Even mania, which is the most curable form of insanity when it has existed for more than two years, is ineradicable. Such statements, however, are only relative. Our present knowledge of mental disease and of pathology is very defective; with a fuller knowledge, with a more accurate experience, it is impossible to say how much these opinions would require to be modified.

One circumstance must not be overlooked in connection with the question of the curability of insanity, and that is, that there is a tendency to recurrence even after complete restoration to health. Perhaps of a hundred persons who have an attack of mania, and who recover from it, fifty will after such recovery again become insane. After insanity has passed away, there seems to exist a hyper-sensitive condition of mind which is ill suited to carry on the rough intercourse of the world, and its society. The man who has recovered is not so well as he was before he was taken ill. Disease always chooses the weak for its victims. Disease, like water, will take the easiest. way; and as the individual who has recovered from insanity is weak * See Prichard, Rush, Esquirol, and Pinel.

in that he labours under this hyper-sensitive condition of mind, he a second time falls under the wheels of some Jugarnatha catastrophe. Any great events in the world's history cause insanity, but the events are seeds which have fallen by the wayside; they require to fall on ground well suited, before they can spring up and blossom in insanity. And the good ground is weakness. Thus we have insanity connected with childbirth, we have it connected with the weakness of childhood, with the weakness of age, with the change of life, and various bodily diseases; and finally we find it in connection with previous attacks of mental disease.

The result, then, of these researches which have been made into the intricacies of this subject are these-that of twelve persons attacked with insanity, six recover and six die insane sooner or later. That of the six who recover three only will remain sane during the rest of their lives, and that the recovery of the other three will not be permanent.*

With regard to the cure, when it does take place, it is to be remembered that health no more than Rome is to be built in a day. Health returns very gradually. It is made up of many simples, and these are only to be reacquired slowly. In some cases it is true that a man is sane to-day and insane to-morrow, and that the change to sanity from insanity may be as rapid; but this is certainly exceptional. It is easy to jump over a precipice, but if one wants to get to the top from the bottom, he must be content to clamber up the hill. It need scarcely be added that, as recovery of health is not a coup, but a gradual process, so must the recovery of responsibility or civil ability be also a matter of time. But as the law cannot recognise the minute distinctions which exist between disease to-day and to-morrow, it cannot recognise graduated responsibility; and it is only necessary to remember that this recovery of mental strength, and, therefore, of the mental qualities necessary for the appreciation of one's position, and rights, and duties, is gradual, that due allowance may be made for those persons who have recently suffered from an attack of mental disease, and that it is safer to regard such person as still irresponsible for criminal acts and incapable of civil privileges, even although the recovery may seem very complete unless the contrary can be proved. Let the presumption be in favour of

* Older writers regarded the tendency to recurrence as one in six and not as one in two.

their want of capacity and their irresponsibility, and no injustice is likely to arise. At the same time this presumption is to be looked upon as liable to be rebutted by proof of its opposite. There is really much virtue in these presumptions of law.

Some medical men have entered into descriptions of the symptoms which they regard as hopeful, and as indicating a tendency to recovery. When these are anything other than the actual return of the thoughts and affections of the insane person in a minor degree to their accustomed channels-in which case they seem to be regarding recovery as a hopeful sign of itself-they are disputed, and no real agreement exists as to what symptoms have, and what have not a prognostic value. It is surely not prognosis to observe that when a man is getting better he is getting better. Such a proposition as A is A, is too full of truth.

CHAPTER XXIII.

ON THE EXAMINATION OF PERSONS SUPPOSED TO BE OF UNSOUND MIND.

THERE is scarcely any subject in connection with the medical jurisprudence of insanity which it is so important that medical men should rightly understand as diagnosis. It is by no means easy to discover when a person is insane. The difficulty is sometimes quite as great in establishing the fact of sanity. Of course the determination of these questions necessitates a thorough knowledge of insanity as distinguished from sanity. But in many cases all a physician's wisdom will not serve to assist him to a satisfactory diagnosis unless he has a considerable amount of that peculiar cleverness in the minutiae of human intercourse which has been called tact. We cannot give rules for the exercise of this ability. All that we can do, in this place, is to suggest a few rules which may guide the questions of the practitioner who is asked to see an individual with a view to signing a certificate, or who has to examine an alleged lunatic with a view to ascertaining the fact of his sanity or insanity, whether it be with regard to civil or criminal proceedings. When we have done this, much will remain to the individual genius of each member of the medical profession who may be brought, for any of the abovementioned purposes, in contact with persons of unsound mind. It is impossible to state rules for the manners of the examiner, and yet any one who has been associated with the insane must be aware how important demeanour is in all cases.

One thing must be remembered by the medical man who conducts an examination of a lunatic, and that is, to be as fair and just as possible. The medical man is not, or ought not to be, an advocate for one view or another. His sole anxiety ought to be to do justice.