wealth, or power, or rank? Was he suspicious? Had he any odd religious notions? Was he violent, dishonest, or immoral? Was he undecided, and did he seem to have lost energy? Was there any failure of memory or of the power of apprehension? Inquiry with regard to any bodily symptoms which accompanied the earliest morbid mental phenomena would be of use; thus, inquiries as to whether he suffered from headache, and if so, in what region; if he was sleepless, or suffered from muscular tremor; if he lost the power of speech, or if it was impaired; if his sensibility was increased or impaired; if he became fatter or less robust; if his appetite was good or bad; and if, in the case of a woman, the menstrual functions were regular or irregular.

? 468. General Rule as to Information received from Friends and Relatives.—In receiving information from other persons, it is always well to ascertain that they attach the same connotation to a term as that which is attached by the recipient. There are many loose words and phrases which have no precise meaning used in this way, such as "strange," "excited," "not himself," "wandering," "incoherent." And when such words or phrases are made use of, the medical man would do well to ascertain the reasons of their use, or the acts done by the individual which will warrant their use, or render them applicable.

8 469. Means of Gaining Access to Patient.-32 325] It is sometimes by no means easy to gain access to the individual who is to be examined. Persons of unsound mind are often very suspicious. Monomaniacs are very frequently full of suspicion; and even those persons who do not labor under monomania, but who have been in an asylum previously, are upon their guard against medical men; so that it is sometimes almost impossible to procure the interview which is necessary if a medical man would form any opinion as to the mental condition of his patient. In many cases, insane persons, of whose morbid condition there could be no doubt, have refused admission to medical men, and have threatened violence if the intention to thrust a medical man into their company was persevered in. In many cases, they would un

doubtedly have carried out their threat, and some of them have intelligence enough to reason that if they did kill a man there would at least be a doubt as to their responsibility, like the lunatic in an asylum near York, who, when Martin set fire to the Minster, was discussing the matter with some of his fellow-inmates, and who said, "He (Martin) will not be hanged, of course: he will escape. They can't hang him because he's mad: he is one of ourselves." But there are many other ways in which the desire for an interview may be frustrated. Persons of unsound mind are aware that no force or compulsion can be used, and if a medical man is shown suddenly into their presence, they may resort to the expedient of leaving the room; and some have, under similar circumstances, sat quiet and held their tongues. There are many ways in which this purpose may be obstructed and the intention frustrated. Under these circumstances, many medical men resort to stratagem. If they are informed that the lunatic believes himself to be a king, they go into his presence as a meek and dutiful subject. If the man is a melancholic, as a clergyman; if an optimist, as a beggar. They repudiate the supposition that they are medical men, and appear before the patient in some less distasteful capacity. Some writers have disapproved of this system, and have argued that it is better to go into the presence of a lunatic in propriâ personâ without any simulation. They argue that when such is the case, the medical man is in a position to question the supposed lunatic more minutely than he could otherwise do, as to his health, his feelings, his sensations, and the like, and that in this way he can invariably reach the insanity of the individual in a shorter time than he could [328] otherwise. It is certainly true that "self" is the object of a lunatic's thought; indeed, lunacy might almost be defined as morbid subjectivity. It is always thus-a dagger of the mind becomes as real to the insane person as an objective dagger. His own intense feeling of self darkens the world, as in a case of melancholia, or lightens it, as in one stage of general paralysis. But against this view it may be urged that if the medical man can get a correct description of the mental symptoms of the person he is about to examine, and can skilfully mix himself up with the morbid impressions of the

lunatic, the insanity will unfold itself immediately, and no difficulty will be experienced. This, however, is by no means easy of achievement, and we should recommend medical men to resort to this expedient as rarely as possible. But obstructions are thrown in the way of medical men in the exercise of this duty not only by the patient himself, but by friends, who may mean well, but who very often do ill. To some near relatives of a patient, it seems a horrible thing to shut him up in a lunatic asylum. There is much of the old prejudice existing in the minds of the public as to the madhouse, so much so, that a friend of our own, who has charge of one of the largest asylums in was asked by a man, who came to remove the body of his wife, "how he had put an end to her." The man added that "he did not object he knew it was often necessary-but he thought it would be a satisfaction if he knew." These prejudices induce many of the friends of patients to throw obstructions in the way of the examining medical man; and many resist the inspection of the relative upon all manner of grounds, and we know of a case in which it was resisted even with force. However, let us suppose those obstacles overcome: the medical man is in the presence of his patient, and the question is, how should he proceed?

2470. Inspection of the Patient.-A medical man, when he has gained access to the patient, should direct his attention to the general state of nutrition in relation to age. The temperament or cachexia, as indicated by the configuration of the body, complexion, color of the hair, movements, etc., ought to be observed. Much may turn upon the observation of whether the patient is of the nervous and irritable temperament, of the sanguine or excitable temperament, of the melancholic or despondent temperament, or of the lymphatic or sluggish temperament, and if the patient presents outward signs of the strumous, arthritic, rheumatic, or cancerous cachexia, of anæmia, or chlorois, or other constitutional vice. The general condition, as regards health and development, should also be observed. The medical man should note whether the head is of large or small size, whether it is symmetrical and well-balanced, or presents any peculiarity of

shape; whether the body is well grown, or stunted, decrepid, or deformed in any part. He ought to pay considerable attention to the expression of the individual before him. That this is of the utmost importance cannot be doubted after a perusal of Mr. Darwin's valuable work upon the expression of the emotions in man and animals, and the many valuable notes which exist in that work as to the physiognomy of the insane. It has, however, been objected that the peculiar physiognomy of those laboring under insanity can only be appreciated by those who have known the expression of the patient in a state of health. But this is not so, although the distinction may be more marked to those who have the advantage of both these classes of observation; who have the effect of change to assist them in discriminating between the influence of health and disease upon that mosaic-work-an expression. Still there is a type of expression easily recognizable by those who have made the face-symptoms of health and disease their especial study. All faces seem to have meanings besides or underneath, as it were, their changing expression; and in disease, it is this meaning that is altered rather than the expressions which pass over it. The tides are changed while the waves remain the same. There are

certain lines of observation to which it may be useful, merely as a mnemonic, to call the medical man's attention. He may note whether the face has the ordinary signs of the intelligence of feeling which is characteristic of persons of the rank and class to which the patient belongs. Whether it indicates innate weakness and imbecility, stupidity or fatuity, abstraction or self-absorption, restlessness and agitation, irascibility, settled grief and suffering, urgent alarm and terror, horror, wonder or astonishment, hilarity, benevolence, religious exaltation, furtiveness or distrust, pride or haughtiness, vanity and self-esteem, erotic excitement or criminal degradation. Play of feature is not unfrequently a sign of health or returning health. When there is one paramount. expression which sits enthroned on the face, there is some probability that it owes its stability to disease. Besides the 327 face, the manner and demeanor of the individual are to be carefully noted. Of course in these recommendations we do not wish to be supposed to refer to those acute forms of BR. INS.

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mental disorder when no such examination is necessary, nor to those well-marked forms of the disease, such as mania, idiocy, or dementia proper. Such rules as I would suggest for the guidance of medical men must be understood to have reference to those doubtful cases in which it is difficult to discover the existence of insanity, for in many cases a careful concealment of all abnormal mental symptoms goes so far as almost to suggest the possibility that it is a part of the disease. Here again we may give certain lines of observation, merely for the purpose of reminding the medical practitioner. It may be noted whether the individual is timid and reserved, or bold and defiant; whether he is peaceful or aggressive; whether he is tranquil or disturbed; whether he is dignified or humble; whether he is bowed down or elated. And muscular tremors, spasms, twitchings, or paralysis, should they exist, ought to be noted.

471. By Conversation with the Patient. To a very considerable extent, the medical man must, in his conversation with persons supposed to be insane, be guided by the circumstances which have been brought to his knowledge by conversation with the friends and relatives of the person to be examined, or by the inspection of which we have just spoken. It is well for a medical man, in most instances, after an exchange of ordinary civilities, to refer at once to the state of the patient's health. It is curious to note how many forms of mental disease centre in hypochondriaces, of one form or another. Certain characteristics are to be noted in reference to such conversation, whether it is upon ordinary topics, apart from the individual's mental disorder or not. First, it is well to observe whether it is vivid or dull, concentrated or rambling, sustained or intermittent. The power of memory ought to be tested by questions both as to near and remote events, and questions as to general and important occurrences, as well as to circumstances which have occurred in the individual's own personal history, will often be found advantageous. It is well to discover whether he is able to tell how many people are in the room; whether he knows his own age. whether he is conscious of the lapse of time, and can remem