The Difficulties of Prognosis in Insanity. HENRY SUTHERLAND. THE DIFFICULTIES OF PROGNOSIS IN INSANITY. Bead before the West London Medico -Chirurgical Society, BY HENRY SUTHERLAND, M.D., M.A. [ Reprinted from " The Lancet." ] XonOon JOHN BALE & SONS 87-89, GREAT TITCHFIELD STREET, OXFORD STREET, W. 1894 M- ' THE DIFFICULTIES OF PR0GX08IS IN INSANITY. Every practitioner of medicine is aware how difficult it often is to give a prognosis in ordinary cases of bodily disease. There is do point in our professional career which is so likely to endan- ger the opinion the public may have formed of our skill in diagnosis and treatment. It can therefore be easily understood that in all cases of mental disease this difficulty becomes much aug- mented, for the reasons that the patient will not assist us by describing his subjective symptoms, and will frequently complain that he is suffering from various bodily complaints of which there are no signs whatever. In forming an opinion about any given case of bodily disease, we are usually asked : '' Will the patient recover ? " " How long will he be ill?" "Will tlie patient die?" "If so, how long has he to live?" And, of course, such ques- tions as these refer just as much to the soDiatic troubles which may accompany mental disease. But in the prognosis of insanity we have to answer in addition the following style of questions : " Will, the patient recover mental health ? " " If so, how soon ?" " Will he die of the mental disease ? " " If he recovers, will he have another attack ? " " If he remains permanently insane, will his life be a long or a short one ? " The classifications which have been made of mental diseases do not throw much light on the subject of prognosis. Greissinger divides them under two heads, curable with functional disorder of the braiu, and incurable with organic disease. Maudsley drops an excellent practical hint in his subdivisions into emotional and intellectual insanity ; emotional insanity being a condition in which horrible crimes are committed, while at the same time the public are unable to detect any abnor- mality in the intellectual faculties. But to my mind the rule of thumb employed at St. Luke's Hospital is by far the best foundation upon which we can rely for a really useful division of the sub- ject. At this hospital curable cases are alone admitted. The medical officer is instructed to ask the friends who are applying for the admission of a patient: "What is his age? What is the duration of the attack? Is it tlie first attack or not? and lastly, what is the form of mental disorder from which the patient is suffering ? " One of the most important points in regard to prognosis is undoubtedly the age of the patient. Thurnam tells us in his statistics that " the pro- bability of recovery is greatest in the young, and undergoes a regular diminution as age advances." Most authors look upon an attack occurring after the age of 50 as hopeless. Bearing this point in my mind I gave a guarded but unfavourable prog- nosis in the case of a Member of Parliament, aged 50, who consulted me some years back. His grand- mother had committed suicide, and his father had died insane. The patient had what he called iine idee fixe, a sort of modified delusion, with other well- marked mental symptoms. I certainly believed his case to be incurable. I prescribed rest, and I attended to his liver, which was much enlarged. Three months later he had completely recovered, and was able to make a long speech in the House 6 of Commons. I must confess I was completely deceived on that occasion, as from tlie history of the case I had every reason to believe it to be in- curable. As a contrast I may allude to the follow- ing case. A youth was brought to me some time ago, aged 18, who was said to be a victim of self- abuse. The late Dr. William Wood, who had a more profound knowledge of insanity than anyone I ever met, pronounced the case to be hopeless. T did not agree with him, but I was wrong. In course of time the patient so far recovered as to be able to start on a sea voyage. But the first night at sea he told his attendant that a horse had put his head in at the cabin window. After this he became violent, was placed in irons and sent home to our asylum, where he now is, having been with us for more than twenty years without any lucid interval. My opinion that his youth would save him from being a chronic lunatic turned out to be incorrect. The number of attacks a patient has had seriously affects the prognosis. A lady at the change of life consulted me. She had become depressed in consequence of having been left a large fortune unexpectedly ; she became suicidal, was admitted, and recovered. I pro- phesied that she would, be a victim to recurrent melancholia. She went out, tried to keep house, but had not the strength to do so. Had a second attack and recovered. Went out again. Got into the hands of two drunken ladies, who swindled her. Had a third attack and returned to the asylum. She left, and was taken in hand by another lady, and has had several attacks since. During one of them I and her brother endeavoured to persuade her to become a Chancery patient. She refused to take our advice, and she is now gradually drifting from a state of melancholia into one of hopless dementia. On this occasion I was right. But in a case later on I was not so fortunate. A lady had six times suffered from puerperal insanity, and had been received in our establish- ment. When her seventh child was being thought of, I advised that she should come to us as a boarder, and thus avoid the fatigues of the London season at this critical period. She passed through her seventh confinement without an attack. She had an attack on the birth of an eighth child. After that she was absent from her husband for 8 two years. But after one year's absence from him, a ninth child was born, the father being supposed to be a cabman. A divorce was the consequence. Since then she has had children and has remained perfectly sane on each occasion. My idea that she would end in chronic dementia has thus far proved incorrect. The form of insanity is also of the greatest importance in giving an opinion. In Dr. Hack Tuke's "Dictionary of Psychological Medicine," there is an excellent article by Dr. Blandford, giving the probability of recovery in every form of insanity. It can only be remarked here that acute cases as a rule are curable, and that chronic cases are incurable. According to a very clever classification of mental diseases, drawn up by a Committee of the Medico-Psychological Association, the following forms are incurable : general paralysis, epileptic insanity, senile insanity, paralytic insanity and perhaps idiocy. In Dr. Mickle's splendid work on " General Paralysis of the Insane," he mentions the names of not less than thirty-six authors who have pub- lished cases of recovery from general paralysis In my own opinion, a recovery from general paralysis, when the symptoms are well marked, never has nor never will take place. In such so- called recoveries, either a wrong diagnosis has been made, or the patient has left the asylum during a temporary convalescence, and has been lost sight of. In the advanced stage the diagnosis of this disease is generally very easy. At least so I and some others thought about a gentleman whose case at the time attracted much attention in the psycho- logical world. This patient's left pupil was always much con- tracted and insensible to the stimulus of light. The right pupil was much dilated. He had marked hesitation in his speech, more especially in his pronunciation of Unguals and labials which, as everybody knows, is very characteristic. I re- member his delusions of grandeur very well. He said he had a horse which was going to win the Derby, that he was about to row for and win the Diamond Sculls, and that he had bought a four-in-hand. The case was carefully watched, epileptic attacks and other signs of advancing disease being daily anticipated. At the end of 10 three montlis the patient made a good recovery, was discliarged from the asylum, and I have reason to know, never had a second attack. We found out afterwards that his hesitation in speech was congenital, that the contraction of the left pupil was due to an old syphilitic iritis, and that the delusions of grandeur were only those which may be met with any day in certain cases of acute mania. Any form of insanity associated with epilepsy is generally considered incurable. The exceptions to this rule are infantile convulsions, epileptic insanity at puberty in girls, and epilepsy after a prolonged and excessive use of alcohol. I was once sent down to Wales to rescue a lunatic who was being robbed of his property. He had been staying for some months in a low village inn, where, in order to conciliate him he was supplied with unlimited beer. I found him reeling about with a glass of beer in his hand which he sipped all day. 1 brought him up with great difficulty to our asylum. On his arrival he had three distinct epileptic fits. We all pronounced the patient to be suffering from incurable epileptic insanity. In this we were wrong, as the patient remained with 11 us for ten years, and never had another epileptic attack, the three on admission having been entirely due to drink. About the same time a lady, aged 28, was sent to us by Dr. Buzzard, suffering from epileptic mania. She commenced having these fits at about 25, and they were increasing in frequency every week. The diagnosis was clear, and the outlook hopeless. After being with us for some years she died from exhaustion, complicated with bronchitis. On this occasion we were all correct in our opinion. A word as to idiocy. The prognosis in this form is most unfavourable but more hopeful than might be supposed. Dr. Shuttleworth tells us that of patients discharged from idiot asylums, after full training, 10 per cent, are self-supporting, and more than 40 per cent, are capable of performing the ordinary transactions of life. Some years ago I was locum tenens at St. Luke's Hospital. No incurable patients are admitted to this institution, and all patients are seen by the committee on their arrival. A patient was brought into the Board room whose relations had told us was suffering from acute dementia. Two other 12 medical men and myself were about to give direc- tions as to the ward in which the case was to be placed, when a layman, who had sat for many years on the committee, exclaimed, " That is a con- genital imbecile." I was sent out of the room to make further enquiries and I found the layman was right, and that the three doctors including myself were wrong in their diagnosis. The patient was not admitted. A baby was brought to me by the parents about sixteen years ago. Forceps had been used at its birth, and the frontal bone had been compressed so that its form resembled the keel of a boat more than anything else. My prognosis was unfavour- able. The girl is now 18, can only articulate as a child of five might do, and delights at this age to play with dolls and to read childish books. She is quite incapable of doing any arithmetic or manag- ing her own estate. It is impossible to describe cases illustrating points in prognosis in every variety of insanity. But we may take it for granted that in any patient in whom there is a regular periodicity in the attacks, all hopes of cure are at an end. I have a lady under my care at the present time 13 who suffers alternately from mania and dementia, each form of mental disorder lasting as nearly as possible nine weeks. I have also a gentlemen similarly affected. In most cases of folie circulaire which have come under my notice, I have found dementia takino- the place of mania more frequently than melancholia. Homicidal insanity is in my experience incur- able. I was called upon some years back to examine a man who had murdered his wife and two boys, and also attempted to murder his two other children, but they refused to drink the poison he had prepared for them. The murderer then placed his own head on the line of a railway when an express train was expected, intending to commit suicide. He was rescued from this position by a pointsman. He was very much attached to his wife and the children he had killed, he had a o-ood balance at the bank, and was in a good situation. He gave himself up and confessed all to the police. I had not the slightest doubt that the prisoner was suffering from the form of insanity known as impulsive, which has been so ably described by Dr. Maudsley, and that he was an incurable lunatic. The judge, however, took a different view, informed 14 the court tliat lie would liave no more murderers let loose on the plea of mental derangement, and was pleased to say that I had thrown dust in the eyes of the jury. After retiring for a few minutes the jury returned to the court, their verdict being '' ISTot guilty, on the grounds of insanity." I visited Broadmoor Asylum some years later, where the prisoner had been sent, and found him to be one of the most maniacal, homicidal patients in the institu- tion and also perfectly incurable. The duration of the attack has naturally a great influence upon the chances of recovery. At the Retreat 80 per cent, recovered who had been treated within the first three months of their attack. During the first year about 60 per cent, recovered. After the first year about 10 per cent, re- covered, Dr. Thurnam says. It may be stated, fairly, that six times as many cases recover within the first year, as recover after the first year of the illness. After two years, recovery is rare. Nevertheless, recoveries have been known to take place after six, ten, and even twenty years' dura- tion. A lady was admitted to our asylum suffer- ing from suicidal melancholia. Before she was 15 placed under treatment she had gouged out her right eye with her thumb, in obedience to the command in the Bible, which says, " If thine eye offend thee, pluck it out, and cast it from thee." After some time the melancholic symp- toms disappeared, and she settled down into what we considered to be a state of chronic, incurable dementia. At the end of seven years she made a sudden recovery, and was discharged, perfectly able to manage her own affairs. In a long experience, I have never known a case re- cover after so long a duration as seven years. We have patients with us now, both male and female, who have been under our care for thirty, forty, and in one case fifty years. It is need- less to remark that the prognosis is perfectly easy in such cases. With regard to sex, it may be observed that a larger proportion of women than men recover. The numbers are 44 per cent, for females, and 36 per cent, for males. One reason for this excess of recoveries on the women's side is that they are less afflicted with general paralysis than are the males. Allow me now to turn to somatic influences with regard to this subject. In my experience • 16 the prognosis in insanity from sunstroke is favour- able in mild cases, but most unfavourable in severe cases. Sir Joseph Fayrer tells us that on post- mortem examination after sunstroke, the brain and its membranes are found congested. My ovrn idea is that when a person is attacked either slightly or seriously by coup de soleil, the sym- pathetic circles of nerve fibres surrounding the arterioles become paralysed permanently, and in consequence do not contract naturally on the blood vessels. Hence a larger amount of blood is conveyed to the brain under even a slight stimulus, and excitement and mania are the result. I was once at a private ball at a seaside town. A young gentleman entered the room, much flushed and talking loudly; he proceeded to pull the cor- net out of the mouth of the trumpeter, lifted the hands of the pianist from his instrument, and pushed the violin from under the chin of the fiddler. He was expelled from the house, every- one saying he was drunk. He recovered next day, called on the hostess, and made his apologies in due form. This young man was an ofl&cer in the army, and had had a slight sunstroke. He was a teetotaler, but feeling tired before the 17 ball, he took a glass of wine to revive himself, which went to his head and caused a transitory attack of mania. I had no reason to disbelieve his statement that one glass of wine produced these awkward consequences. But insanity from a severe sunstroke is a very formidable and incurable form of mental disorder. I had for many years an Indian General under my care, wlio was one of the most dangerous patients it has been my lot to deal with. His condition was entirely due to a severe sunstroke he had sustained during an unusually hot summer in India. In such cases I have observed that there is a period of incubation. The symptoms most characteristic of the disease do not appear till some months after the exposure to the solar rays, although perhaps in the meantime a slight intel- lectual and emotional departure from the healthy standard may be observed. The occurrence I am about to relate took place during the Indian Mutiny some forty years ago. The General had been told off to guard a cer- tain number of commissariat waggons. His story, which he presented to me most modestly, has neither a clinical nor a pathological interest, but 18 • well illustrates liow the mind may become nn- hino^ed even some months after a sunstroke has visited the patient. He said : " I was in command of a party of forty horsemen.- We came suddenly upon a force of 400. It was a case of ten to one. It was my duty to retire, but I felt that murder was in the air. I gave the orders to my men to charge. My trumpeter was shot down on the right of me, and my orderly on the left of me. I cut my way in, and I cut my way out. All perished except myself, and I thought I was well out of it." In these few words were expressed what ap- peared to me to be a most romantic episode of military life. Unfortunately, there is a seamy side to the story. The Greneral was tried by court martial, and his behaviour was so eccentric on this occa- sion that a medical examination as to his state of mind was ordered. He was found insane, and sent from India to our asylum, where he remained for twenty years, and finally died an incurable lunatic. I now pass to the prognosis in cases of alcoholic insanity. There is no class of cases which recover 19 so rapidly as do those of acute alcoholic insanity, due to one inordinate drinking bout, and there is no class of cases more incurable than those wlio during a long course of years have soaked them- selves day by day in stimulants. A captain in the Royal Artillery was admitted suddenly one afternoon to our asylum. He had indulged in an unusual amount of alcohol, and had become mischievous, and almost homicidal. He had taken his wife in his arms and had held her over the balcony of his house, and threatened to dash her on the spikes of the area railings below. The police were called in and he was certified, and sent to a harbour of refuge. On admission he was in a state of violent mania, and passed the night in the padded room. I visited him again next morning, and after a three hours' examination, could find no indications whatever of mental aberration. He had completely recovered in one day, the cure being simply due to abstinence from stimulants. By his own request he was detained as a boarder for a week, as he said to keep him from the drink. On his discharge he took more freely than ever to alcohol, and died six weeks later from delirium tremens. 20 The prognosis was, howevfer, very different as to even a temporary recovery in the case of an old gentleman, aged 76, I was sent for to attend one Sunday morning in the Regent's Park. He had for not less than forty years been in the habit of getting drunk frequently, although able to go down to his office in the City, and manage his affairs fairly well. At last he became so unpre- sentable that his sons were obliged to protest against his taking any further part in the business. The unfortunate part of the case was that the old gentleman would neither die nor become insane. In France a conseil de famille would have been held to decide what was to be done with this gay young worshipper of Bacchus. Unfortunately no such law obtains in England. I only saw him once, but I heard afterwards that his and his son's business was going from bad to worse, owing to his un- fortunate propensities. In this case it was suggested to my mind that the law of China as to the treatment of lunatics might have been justifiably employed. In this enlightened country they have but one method. All lunatics there are treated by decapitation. I have before alluded to Dr. Maudsley's clever 21 subdivision of mental diseases under the two beads, emotional and intellectual insanity. Emotional insanity is a very important form to recognise. It is very rare. It leads to borrible crimes being committed by its victims. The in- tellect being nearly, but not quite, intact, it is impossible to persuade the relations that there is anything wrong with the mind of the patient. The prognosis is usually most unfavourable in this form. I have a lady at present under my care, residing in the house of a medical man. She has been insane for about five-and-twenty years. On one occasion a high authority in lunacy visited her and pronounced her to be perfectly sane, I asked him how long he had talked to her. He said ten minutes. I told him to go back and give her ten minutes more. In the course of the second tea minutes all the delusions and hallucinations came out, and he was obliged to confess that she was an incurable lunatic. This lady knows a great deal, but not all, about her investments and dividends, but ask her to describe a carriage accident or any place of amuse- ment she has visited, she breaks down before the end of even a short narration. She indulges in 22 tliemost filthy conversation, rending it impossible for ber to take ber meals witb tbe family. Tbe case is incurable. I bad anotber very curious case under my care a few montbs back. Tbe patient was a clerk in Somerset House, engaged in tbe most complicated transactions during many bours of tbe day. Ex- cess of alcobol was tbe root of tbe evil in bis case. If be were in tbe public streets or an omnibus, be fancied tbat people put up tbeir bands to tbeir moutbs, stamped tbeir feet, or made grimaces on purpose to annoy bim. He bad a brotber and a wife, one of wbom always accompanied bim to and from tbe oflSce. It was useless to tell bim tbat tbey, wbo bad met tbe same people be bad in tbe street, bad never seen tbem do anytbing wbicb migbt be construed into an insult. He became worse, and I obtained leave of absence for bim for six iQontbs. My prognosis was tbat as long as be kept from drink be would be perfectly sane. He became a teetotaler and recovered perfectly. Tbe extraordinary part of tbe case was tbat tbis man, afflicted witb delusions of suspicion, was able to carry on severe mental work all tbe time be was apparently insane. 23 As to delusions generally it may be saiel that it" the patient has a variety of them, quickly changing and accompanied with noisy violence, the outlook is hopeful. Fixed delusions existing for more than a year, and continuing when the acute symptoms subside, mark the case as incurable. From amono- such patients we obtain our asylum kings and queeus who are content to work in- the scullery or laundry during the day, and assume court dress or a regal crown when festivities take place in the evening. But of all delusions those that are pro- gressive are the worst as regards prognosis. Your general paralytic will commence by telling you he is going into Parliament, that he has been knighted, made a baronet, created a peer, that he is the Prince of Wales, and finally, that he is God Almighty Himself. This is an important point to be remembered in diagnosing a case of general paralysis from one of chronic mania. A great deal of light is thrown on prognosis by observing the postures and movements of the insane. I have a young lady at present under my care who sits all day with her arm over the back of a chair and her head leaning on it. This position has remained 24 fixed during the day for three years. The outlook is hopeless. Another lady, young on admission, rubs her nose continually, making it very red. This she has done for many years. A gentleman under my care walks round two Hower beds in the garden, his course taking the shape of a figure of 8. He kicks anyone who gets in his way, but is otherwise harmless. One old gentleman has for twenty years rolled a pocket handkerchief up in a ball and turned it round and round in his left hand. With his right he continually percusses his knee, and thus wears out the cloth of his trousers in less than a week, necessitating endless patches. All monkey tricks in the insane mark the case as incurable. One of our patients filled two walnut shells with fgeces, gummed the two halves together, and gave the walnut to an attendant to crack. This he did with his teeth, much to the delight of the patient and the discomfiture of the attendant. This gentle- man was insane for upwards of thirty years. Hsematoma auris almost always is found amongst chronic incurable cases. I have a lady with a marked swollen ear at present under my charge, 25 who will never recover. I have, however, seen hgematoma in sane people, generally prize fighters. I exhibited a professional boxer at the Clinical Society some years ago, who had this peculiarity. Certain bodily complications have great influence on the outlook. For instance, the recoveries in puerperal insanity are very numerous, but if the case should be accompanied by albuminuria the patient almost invariably dies. If the patient should increase in weight, the mental condition remaining unaltered, the outlook is very unfavour- able. A West Indian lady, admitted in 1891, weighed 8 st. 13 lbs., and on the third anniversary of her admission, that is in 1894, she had increased in weight to 12 st. 2 lbs. This was an increase of three stone, or one stone a year. Her delusions are always the same, that she is suffering from various bodily complaints, of which there are no tangible proofs. Syphilitic insanity in the early stage is fairly curable, but later on ends in the death of the patient. I had an Indian colonel under my care for many years suffering from syphilitic mania. Not being satisfied with my treatment, a very eminent physician was called into consultation. A 26 third doctor, a friend of tlie patient's, was present. The eminent diagnosed the case as one of syphilo- phobia, that is, a dehision on the part of the patient that he has contracted syphilis. I made no remark, and the eminent departed, T\'ith his fee. When he had left the room I turned up the Colonel's trouser and showed his friend, the third doctor, a large open, brown, syphilitic sore, which the patient had had on his shin for many years. The patient died a few months later. The condition of the blood in the insane is a great guide in giving an opinion as to how long a patient has to live. When I was at the Wakefield Asylum I examined under the miscroscope the blood of some hundreds of lunatics. The results were very satisfactory. It would take too long to enumerate them here, but I cannot resist mention- ing one point which was to me very striking. I found that if in general paralysis of the insane a much larger proportion of white corpuscles as compared with the red was present, the patient was sure to die within four days, although he might apparently be in fairly strong health. This and my other observations have been confirmed by Dr. Lauder Lindsay nnd Dr. Rutherphail. 27 Before concluding I should like to say a word or two about the diagnosis of recovery in a patient. Recoveries are always calculated on the admis- sions. According to Thurnam they may vary from about 25 to 50 per cent., but, as I have said, at St. Luke's Hospital where only curable patients are admitted, the number of recoveries reaches 60 per cent. Generally speaking a rapid recovery is likely to be succeeded by a second attack. A slow recovery is much more hopeful. Convalescence from in- sanity is indicated by quietness of mind in the patient ; he speaks freely about his disease ; he does not perpetually bother the physician as to when he is to leave the asylum, he asks to see his friends, and be returns to his usual employments. An outburst of weeping in females during an attack of acute mania is a good sign, as showing that the patient is aware of her condition. On the other hand a contented state of mind points to increasing dementia. Esquirol remarks that many patients who are considered cured by their relations are not so really. In this I quite agree. In proof of this I may mention that not less than three patients 28 removed from our asylum by the wish of friends, and contrary to our advice, committed suicide, one on the very night of his discharge. Patients are frequently sent back to me to be examined after they have left us, in order to as- certain whether or no they are cajDable of managing themselves and their affairs. You prepare a list of their former delusions from your case book, and tax them with them, one by one, and draw your con- clusions from their answers. You also can get valuable information from the attendant who usu- ally accompanies them, as to their actions and habits being sane or insane since they left the asylum. In almost all cases, three months after discharge there are still present traces of the old disorder. Frequently the patient looks lost and distressed, the angles of the mouth are drawn down, there is a general feebleness about the outhnes of the features, and the bodily health is never quite re- established. They complain of great irritability, and they are easily moved to tears. Their letters also eloquently express their undecided and vacil- lating state of mind. In females there is a w^eak smile on the face and 29 frequent showing of the gums, the eyebrows are elevated as they speak, and there is a marked transverse corrugation of the forehead expressive of doubt and anxiety. But it is only by long experience and a careful examination of facts that we are able to determine from these rough rules what is to be done with the patient. The importance of giving a correct prognosis in case of mental disease cannot be over estimated. Frequently large pecuniary interests depend upon our opinion, as for instance when a large sum is offered to the patient if his life is only to be a short one, as in general paralysis, or if he is to receive a pension, if his life is to be a long one, as in chronic melancholia. The matrimonial prospects of both sexes are also much affected by the form of insanity and other points which have to be gone into when an alliance of this kind is contemplated. Cases of hysterical mania in young girls are very hopeful as well to recovery as to the 7?o??.-probability of a second attack. Any girl who has had two attacks of insanity ought not to marry, in my opinion. The parents of both parties will come and con- sult us on these difficult and delicate matters. One 30 rule I always lay down in such cases, and that is, that the sane contracting party should be told the whole truth about any previous attack from which the other may have suffered, and then, if he or she choose to proceed with the engagement they do so with their eyes open, and take the responsibility on themselves. We have had the wife of an eminent medical man with us for some years. During her engagement she told her future husband that she had some dreadful secret to reveal to him. He thought she referred to some previous engagement. She said to me afterwards : '' He little thought I had two asylums at my back," meaning she had been twice certified as a lunatic. Six weeks after mar- riage she became insane, and remained so for many years, the unfortunate husband having all this time to maintain a wife who was worse than dead to him. Finally, our method of arriving at a correct prognosis may be compared to weighing in a pair of scales those points, which, on the one hand, are in favour of, and on the other, are against the chances of recovery in any given case, such points, however, not being estimated by their number, but by their quality. Experience alone can teach us the value of each individual point. But when the 81 importance of the subject is considered, it is surely our duty to neglect no opportunity of improving our natural powers of observation, and thus be enabled by the accuracy of our opinion to confer health and happiness upon our less fortunate brothers and sisters. RC602 Su8 Suther 1 and The d i f f i cu 1 1 i e a of jgr o gno a 1 3 in insanity