insane-may be asked to determine whether or not mental unsoundness really exists; to predict, as far as practicable, what will be the duration and termination of the mental unsoundness, if present, or to say as nearly as possible, the time at which the mental unsoundness originated. And it is with these objects of examination that we have principally to do in this place. The physician, however, will endeavor to ascertain the morbid conditions upon which the mental unsoundness depends, to discover the conditions which predisposed to insanity or directly induced it, and to decide what remedial measures will most certainly and speedily secure its diminution or removal. In these researches, he will have recourse: (1) to conversation with the relatives, friends, acquaintances, or attendants of the alleged lunatic, and in that way will make himself cognizant of his previous history, of the mode of origin of the supposed mental disorder, and of the symptoms which had manifested themselves previous to the date of the examination; (2) to an inspection of the alleged lunatic, so as to observe and interpret any outward manifestations of mental unsoundness in physical degeneration, muscular action, deportment, or dress; (3) to conversation with the alleged lunatic, so as to elicit the state of his or her intellect, emotions, desires, and will; (4) to physical exploration of the organs and viscera of the alleged lunatic, so as to obtain information as to his or her general health and the state of the nervous system.

467. Conversation with Relatives and Friends of the Patient: Difficulties of the Investigation.-Great care must be taken in weighing the evidence of insanity which is conveyed to the medical man by those who are about the patient. In many cases, the practitioner must exercise a sound common sense in judging of the reliability of those who communicate facts which they regard as indicative of insanity to him. He must take into consideration not only the motives which they may have for speaking the truth or telling a lie, but even if he is assured of the perfect good faith of those with whom he communicates, he must be convinced of their ability to communicate the facts which they pretend to tell. In many instances, if you ask one of those persons

who are acquainted with the symptoms of insanity, by reason of constant attendance on the insane, they are utterly unable to give their reasons for regarding any of the patients under their care as insane. If you ask an attendant in a lunatic asylum how he knows some particular patient is insane, he will answer, "He would not be here if he was not mad." It requires much care and some real ability to arrive at a conclusion as to the relative value of testimony, and medical men ought to be careful in weighing the facts which are communicated by the relatives and friends of those whom they examine. Many things will be mentioned to the medical man as proofs of the existence of delusions which are not evidence at all; and, on the other hand, actual delusions, because they seem connected with ordinary facts, will often be overlooked by relatives who may have every desire to be accurate. Thus, a sudden change in the habits of an individual will, to a medical man, often indicate the presence of mental disease, although the conduct after the change may not, to an ordinary observer, appear in any way extraordinary. Thus, we have met with a case in which, in an old gentleman, the beginning of undoubted mental disease was indicated by a careful brushing of the back hair and a flower in the button-hole of his coat. Imagine a medical man in a witness box stating such circumstances as facts indicating insanity! Imagine his examination! "Do you say that you regarded this gentleman as mad because he brushed his hair and wore a violet in his button-hole?" "Yes." Imagine the counsel's look at the jury, the Judge's puzzled expression, the jury's broad grin! Everybody in court seems to have put their shoulders into their ears, and the general impression is that the patient is sane and the doctor mad. Yet in the case alluded to, these circumstances did indicate a complete change in the mental condition of a man upwards of sixty years of age; and a complete change at such an age is not a change for the better, and is indicative of the gravest deterioration of the organization. But it is evident from this that, if you failed to make a Judge, a counsel, and a jury understand that such circumstances were significant, such little things would probably escape the observation of the friends of the supposed lunatic, and in this way the in

formation the medical man receives is generally defective and often untrustworthy. Even in judging of delusions, friends show a sad want of competence. A man may say he believes his wife to be unfaithful, and that may be a delusion or it may be a well-founded belief. There is often much difficulty in ascertaining which of these a statement arises from. If you ask a man why he believes his wife to be unfaithful, he may have some delicacy in stating the reasons he has for thinking so; but you are not therefore to conclude that [323]it is a delusion. In such a case, all the circumstances of the case must be considered: his mode of admitting his belief, his whole language and conversation, and any derangement of physical health which may indicate the presence of mental aberration. Even where the belief is in some fact that at once shows that the mental impression must be a delusion, care must be taken. Galileo was put in prison because he said the earth moved round the sun, and Soloman de Caux was confined in a lunatic asylum because he said that he could make ships and carriages go by steam. We boast of enlightenment in these days, but some of our prejudices are quite as deeply rooted as that in the Ptolemaic system of astronomy, and we have ourselves met a medical man who would scarcely hesitate to sign a certificate for any "good old tory." Again, even where those who are about the patient are capable of giving useful and accurate information, there are often circumstances which would induce them to be untruthful. Thus, a family is tormented with the erratic vice of one of its members; its respectability is in jeopardy; it looks forward to a time when he may be placed in a felon's dock; their position in society is at stake; it seems to them that the kindest thing that they could do for "poor George" is to put him in a lunatic asylum, and so keep him out of prison. And all these reasons tend to render the information they give to members of the medical profession less trustworthy than it might otherwise be. Or it may be a husband is anxious to get rid of a wife with whom he finds he is unable to live happily. It may be that there are reasons for this want of comfort: his wife may be a drunkard, and he may endeavor to induce medical men to regard this habitual drunkenness as a symptom of mental disease. And we would

say, in passing, that medical men should always be careful to ascertain that the patient whom they propose to examine is sober at the time of the examination. Cases have arisen in which this precaution has not been taken, and in which consequences of the most unpleasant description have ensued. Many other circumstances may point to a similar tendency on the part of informants. Thus, an individual may be accused of a crime, and all his friends may combine to give such an account of his past life as, taken in connection with the act itself, may lead to a belief in the mental unsoundness of a person who is actually sane. Again, on the other side, it is often the [324 interest of those to whom the medical man must turn for information to prove that the person under examination is perfectly sane. The individual may have been boarded with a private family, and certain acts may have suggested the necessity of his removal to an asylum. In such a case the persons on whom the examining medical man must rely for a statement of the case, in so far as its recent history is concerned, are those whose object it is to prove that all the insane acts, which suggested the necessity of his removal to an asylum, were harmless eccentricities. All these circumstances are mentioned with laughter as if nobody thought anything of them; and we know of a case in which the desire to keep a person who paid a large board made the people regard the biting off of the head of a kitten as a pleasantry and an excellent joke. Other cases have been indicated in earlier parts of this work which will suggest to the reader circumstances in which it would be for the interest of those who are about the patient that the truth should not be spoken. In all such cases it behooves the medical man to be exceedingly vigilant; for we need hardly say his duty is to speak the truth, and while there may be excuses for the untruthfulness of the near relatives of an individual if, in the supposed interest of a friend, they depart from truth, there can be no excuse for the medical man who so far forgets himself as to sacrifice one jot or tittle of the code of truth for the sake of a paltry fee, or for any other reason that can be urged. Feelings may excuse a father who would save a son from a gallows lying as to his past history, which he cannot look upon for his tears, but no feelings ought to influence the judgment

of the medical man, who is none the less on his oath before God because he has not kissed the book. But to get at the truth even from those who are able and willing to speak it, one must have the capacity to elicit it; and one or two hints as to the sort of investigations which it is well to make in conversations with the relatives and friends will not be thrown away. First, with reference to cause, when the medical man has ascertained the name, age, occupation, and social condition of the patient, it would be well for him to inquire as to the precise stage of his or her development, for special proclivities towards mental disease are connected with pubescence, adolescence, senility, and with the epoch of the change of life. He ought to inquire as to hereditary predisposition to insanity. If that is found to exist, it would be well to ascertain the exact character of the psychosis, and inquiries ought to be made as to the existence in the ascending line of paralysis, apoplexy, hysteria, chorea, neuralgia, habits of intemperance or licentiousness, and even as to the known existence of tubercular diseases and phthisis in the family. Questions as to injuries to the head or the spinal cord will often elicit information valuable to him who would form a right estimate of the disease. Inquiries should be made as to the patient's previous health; as to his having suffered from fevers with delirium, delirium tremens, or syphilis; as to previous conditions, such as unterogestation, lactation, starvation; as to previous habits, such as intemperance or licentiousness, use of narcotics (opium, chloral, etc.) and as to the physical conditions of health in his past history, such as exercise, absence of intellectual strain, of anxiety, of grief or disappointment; as to the state of the affections, and religious convictions. The medical man ought to ascertain whether the incursion of the disease has been sudden and unexpected, or slow with visible and well-marked stages, or slow with obscure variations in degree. The character of the early symptoms, although it is difficult to get at them, should be ascertained, and the suggestions most likely to elicit information would be: Did a change come over his character, and what was that change? Was he depressed? Was he excited, restless, or easily agitated? Was he sometimes depressed, and sometimes excited? Had he extravagant notions of his