and intractable. I have a medical certificate before me of the patient's insanity: it appears to be distinctly puerperal mania." From this we gather that, in the opinion of this medical man, "death and the skies" are "incoherent subjects." What is meant by "incoherent subjects" we do not profess to understand, any more than we know what a "mental conversation" or an "incoherent laugh" is. But we learn more, that a "medical certificate" may be "distinctly puerperal mania;" that all these things are facts, that they indicate insanity, and that they have been observed by this highly intelligent medical practitioner. If medical men would read the marginal notes which are appended to the printed form which they are required to fill in, and if they would pay some attention to what they read, these stupid mistakes could not arise. It is best to form every statement of fact into a sentence, and to be careful that, when speaking of what you have yourself observed, you do not introduce matter which has been communicated by others. Vague terms are to be carefully avoided; and opinions are never to be stated as facts. The necessity of the statement of such rules is shown by the above instances of blunders.

2475. General Rule for the Guidance of Medical Men who Conduct Examinations.-Whether the examination be instituted with a view to arriving at an opinion on which to found a report, on which to found evidence which may be demanded in a court of law, or on which to fill up and sign a certificate for the incarceration of a lunatic in an asylum or hospital, it is well for the medical man who conducts the inquiry to endeavor to be as fair and just as possible. The medical man is not, or ought not to be, an advocate of one view or another. His sole anxiety ought to be to do justice. [321] He is, as it were, in the position of a Judge. He has to weigh and consider the facts which he himself observes, and the evidence which is communicated to him by others. The best Judge is an advocate after all, but it should be the strenuous endeavor of each one who is in such a position to be as impartial as it is possible for a man with a human bias to be. One important observation, which is applicable to all examinations conducted by medical men, is, that they should never

endeavor to trap the lunatic. Such arts are allowable in a court of justice where there are counsel on either side and a Judge who is capable of watching over the interests of justice, and at the same time is not incapacitated from regarding the interests of the accused. But in such examinations as those which are at present under consideration, any such arts are entirely out of place. Still medical men are not unfrequently induced to indulge in such Old Bailey tricks from the pleasure they feel in exercising their own ingenuity. Such a practice cannot be too severely censured.

2 476. The Prognosis of Insanity.-The examination of the physician must almost always, after the fact of insanity has been established, be of such a nature as to enable him to predicate with some certainty as to the probable course of the disease and the prospects of recovery. It is very evident that this question is one of the utmost importance in relation to the medical jurispredence of insanity. If the attack of insanity under which the individual is laboring is of a transient nature, if the violence which symptoms the disease will soon pass away, then it may be well to forego the extreme measure of removing the patient to an asylum. Again, where the chances are great of a speedy recovery, it would be ridiculous to take out a commission of lunacy, which would only occasion expense and inconvenience to the individual after his recovery, in having it set aside. In every case, a prognosis is of much importance.

2477. Of the Statistics of Recoveries.—(315) Many people have a passion for statistics, just as a miser has a passion for money. The accumulation of figures in the one case is often as useful as the accumulation of figures in the other. So a great many medical gentlemen who have insane patients under their care have made large collections of these facts, or what they call facts, and have imagined that they have been doing good service to the science of medical psychology. Well has Emerson said, "It is not new facts that avail, but the heat to dissolve everybody's facts." There have been very few furnace heads applied to that heap of rubbish which is called facts. We must be content to see what these

rags are. As to the number of recoveries from insanity, the statistics which have been offered to the public are, so far as we know, exclusively derived from returns furnished by large hospitals for the insane. Even if these were accurate in themselves, this circumstance would render any inference as to the curability of insanity generally worthless. We have heard a good deal about "hospitalism" recently. Medical men have asserted that an hospital is to the grave what the jackal is to the lion. Sir James Simpson was at the head of those who thought that hospitals were bad things, and that people were taken to infirmaries to die. Now, we have seen a tendency to the spread of this idea. If a great man has an idea, there are a dozen little men who run away with it, make some slight modification in it, and then call it their own. The retail dealer often has more credit for the excellence of the wares than the maker. So this idea has been adapted, and a new department of sanitary science has arisen which we may call "asylumism." According to this made down theory, asylums are bad places, and the places least likely to conduce [316] 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

1 On the Statistics of Insanity.

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 manage

ment.

478. Prognosis Generally.-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.

479. As to Recovery.—317) 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

See Prichard, Rush, Esquirol, and Pinel.

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 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 cpinions would require to be modified.

480. The Tendency to Recurrence.-One circumstance must not be overlooked in connection with the question of the durability 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 [318]in that he labors 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