of words by means of block letters, or the letters of a printed page. If the right hand is paralyzed, he will use his left, until by perseverance he has acquired considerable facility of writing. In cases where the defect extends both to written and spoken language, and the thoughts can be expressed by pantomime only, the manner in which this is used will furnish some clew to the mental capacity. If highly expressive, it is a proof, no doubt, that the understanding retains some degree of strength and activity; but it can never, by any possibility, place beyond a doubt the complete exemption of the intellect from the effects of disease. If, on the contrary, the patient never resorts to signs, or to a very few, and shows no improvement in the use of them, the conclusion is irresistible that the mind is in a state of dementia. In cases where the hearing is unaffected, and there is reason to suppose that the patient understands both spoken and written language, while he makes but little or no attempt to communicate his thoughts by letters, we cannot avoid the conviction that for all rational purposes the mind is gone.

§ 388. Valuable indications respecting the mental condition in this class of cases may be derived from the manners and habits of the patient. To the practised observer there will always be discerned a wide difference in this respect, between one who has lost his mind with his power of speech, and another who, with his loss of speech, retains his mind in its original integrity. This is a matter which hardly admits of definition or description, and therefore the reliance which is deservedly placed upon it can scarcely be appreciated by any but those who have observed the phenomena of dementia on a large scale. One of them may be referred to hero as particularly worthy of attention, because it would be a conclusive test in cases that might otherwise be doubtful. In the graver forms of dementia, the patient occasionally neglects to obey the calls of nature in a suitable manner, although a vigilant attendant will generally obviate this disagreeable incident by observing the symptoms of uneasiness, and leading him in season to the place of relief. By one of the medical gentlemen, whose opinion was obtained in a celebrated will case lately adjudicated in a neighboring State, this symptom was confidently relied on as a conclusive proof of dementia. It could not have arisen in the case in question, he thought, from paralysis of the sphincter muscles, because, in the first place, the paralytic difficulty was hemiplegia, not paraplegia, in which the influence of the will over these muscles is suspended; and, in the second place, such an affection would necessarily give rise to unseasonable evacuations habitually, not occasionally. Neither could it have proceeded from morbid irritability of the rectum or bladder, for such an affection would have led to unusual frequency of the evacuations, — a fact which did not appear in the evidence. It would also have been accompanied by other indications of disease that would have forced themselves upon the notice of the medical attendant, and required some measures of relief. The only other possible cause of this disregard of the promptings of nature is dementia, — that mental condition in which the individual is too careless of propriety, too indolent or too irresolute to act properly upon the impressions which he perceives. He is aware of what is coming, he fumbles about his pantaloons, looks towards the customary place of relief, or eats with redoubled quickness if he happens to be at his meal; but if his attendant is out of the way, or fails to recognize these premonitory signs, he readily ceases to trouble himself about the matter, and lets things take their course.1 Who, much conversant with the insane, will fail to be impressed with the correctness of this diagnosis?

§ 389. In testing the capacity of one deprived of the use of speech by cerebral lesions, we must guard against the common error, not unfrequently made even by cultivated and intelligent men, of confounding incidents expressive of only the most common wants and affections of our nature with such as imply some effort of the reflective powers. A large portion of 1 Dr. L. V. Bell, Opinion in the Parish Will Case, iv. 484.

our movements — those connected with the simple routine of life — become automatic, and are performed without much exercise of mind. The ability to comprehend questions relative to trivial matters of fact, to execute messages, even to play games of skill, indicate but little mind; and yet it is just this kind of intelligence which is often supposed to prove the complete integrity of the mind. Another common mistake in testing the mental powers of paralytics, of whatever class, is that of concluding, that because the patient comprehends the terms of a proposition he necessarily comprehends the merits of the case which it involves. A man may be very well aware that he owns a certain estate, and that some one is ready to buy at a certain price, and yet be quite incompetent to decide whether or not, under all the circumstances of the case, this price would be a fair one. In making his will, he might he aware of the existence of all his relatives, and recognize their natural claims upon his bounty, while incompetent to distribute that bounty upon any principles of equity and fairness. Surely, something more is necessary in such things than the mere comprehension of language, and yet large amounts of property have been disposed of to one and another upon a principle of discrimination calculated to excite suspicion, where it is doubtful if the testator, himself deprived of the power of speech, understood even the language in which these dispositions were suggested by others.

§ 390. Neither are we too hastily to conclude that expressions of assent or dissent imply a correct understanding of the merits or the terms of a proposition. By persons of shattered intellect such expressions are often used automatically, and are utterly unreliable, unless carefully tested by varying the form of the question. A paralytic recently under my observation would converse, for a few moments, intelligently and pertinently; he had the air and demeanor of a gentleman, and he observed tolerably well the little proprieties of life. As far as the train of thought was mechanical, so to speak, he got on pretty well; but the moment any effort was needed, he utterly failed. He would assent to any proposition or dissent from it, according to the form in which it was put. For instance: "Major" (he had held a commission in the French army under Louis Philippe), " you were in the battle of Waterloo, I believe?" "0 yes, I was there." "In Jerome's division, in the assault on Hougoumont?" "Yes, I was with Jerome." "But how could that be, Major? The battle of Waterloo was fought before you wore born. You could not have been there." "0 no, I was not there."

§ 391. The temper and disposition often suffer, in common with the intellect, in consequence of paralytic attacks. The patient becomes irritable and peevish, not easily pleased, and impatient of salutary restriction; he loses his self-possession, and the least emotion is accompanied by immoderate weeping or laughter. Dependent upon others for assistance and comfort, a little adroitness readily subjects him to their will, and makes him execute their purposes.

§ 392. The effect of time on the immediate consequences of apoplexy and paralysis — the loss of speech, of the use of the limbs, of the moral and intellectual vigor — is various. They may remain unchanged for months or years, until increased by another attack; they may completely or partially disappear, either under the restorative influences of the constitution, or perseverance in the use of appropriate means. This kind of improvement is a fact of much medico-legal importance, and indicates the necessity of a careful discrimination of its different stages.1

CHAPTER XIV.

DURATION AND CURABILITY OP INSANITY.

§ 393. With the exception of that kind of dementia that occurs at other periods of life than that of old age, mania is the only form of insanity that admits of a cure; and though its duration is various, the probability of this event is almost entirely destroyed within a comparatively short space of time. This is abundantly evident from the statistics that have been published from time to time by the heads of various lunatic establishments. Esquirol concludes, on data furnished by the returns of the principal French and English hospitals, that the absolute number of recoveries is about one in three; and also that the number of recoveries varies in different establishments, from one in four to one in two or two and a half of the whole number of persons affected. Prichard regards this computation of recoveries as much below what really takes place under favorable circumstances, and the reports of American hospitals give an average of recoveries not far from forty per cent. Such, however, is the imperfection of statistics on this subject that we can speak with but little confidence respecting the proportion of recoveries. We only know that in cases subjected to judicious treatment soon after the attack, recovery takes place in the proportion of six or eight in ten; while in those which have continued a couple of years, there is little prospect of recovery. Pinel, in a memoir presented to the Institute in 1800, was led to conclude from a selection of cases expressly chosen for this purpose, that a greater number of recoveries takes place in the first month than in any succeeding one, and that the mean time of the duration of the disease when cured