CHAPTER XI.

THE DIAGNOSIS OF INSANITY.

THERE is no point connected with the subject of insanity which is of more importance than that of its diagnosis. On the answer which the physician may give to the question, "Is the person insane?" depends often not only the liberty of the individual, his right to his property, his ability to make a will or a contract, but even life itself. Heretofore physicians have frequently allowed legislative bodies and courts to tell them what insanity is. They have confounded insanity with irresponsibility, whereas many of the insane are wholly or in part accountable for their acts, while many who are regarded as sane are not accountable.

Of course it is entirely right and proper that there should be an unyielding line to separate legal sanity from legal insanity, and no better one than that based upon a knowledge of the nature and consequences of an act, and that it is or is not a violation of law, can be devised. Any one possessed of this knowledge is legally sane, and legally responsible for his

acts.

But when it comes to the science of the matter the thing is very different. As I have defined insanity in a previous chapter, it consists of "a manifestation of disease of the brain, characterized by a general or partial derangement of one or more faculties of the mind, and in which, while consciousness is not abolished, mental freedom is weakened, perverted, or destroyed." An intellectual subjective morbid impulse, by which a person-as, for instance, the young lady whose case is given on page 383-is compelled to repeat mentally over and over again certain words, or who, like Professor Ball's patient (page 388), could not get rid of a ridiculous idea, is certainly insanity. "One or more faculties of the mind" are deranged, and "mental freedom is weakened, perverted, or destroyed"; but a person the subject of such derangement is not insane according to the legal standard, and ought to be regarded as fully responsible for any crime he or she may commit.

Again, take the instance of the patient whose case is detailed on page 527 as an instance of paralysis of the will. Such a person clearly comes within the definition of insanity,

and yet it would be absurd to regard a person as irresponsible for a violation of law, simply because he is unable to determine which shoe to remove first.

In former times the idea of a lunatic was very different among physicians, lawyers, and laymen, from what it is now. There was entire uniformity on the subject, for no one was considered insane who was not a raving maniac, a person who did not know the nature and consequences of his acts. But science has advanced more rapidly than law, and many varieties of insanity are now known to exist which, when Blackstone wrote, were not regarded as departures from the ordinary standard of sound mental health. We know that the smallest deviation from the normal state of any organ of the body impairs to some extent the functions of that organ, and consequently deranges the physical health of the individual. A small fraction of a grain of tartarized antimony taken into the stomach excites nausea, and perceptibly disturbs the system generally. The hundredth of a grain of atropia dropped into the eye destroys for hours the clearness of vision. In both of these instances there is, for the time being, bodily disWhy, then, should the brain form any exception to the other organs, and why should not slight deviations from its normal mode of action be regarded as instances of mental disease? They are just as much evidences of brain disorder as pus in the urine is evidence of disorder of some portion of the genito-urinary system.

ease.

It is from this stand-point-the purely medical one-irrespective of what parliaments and legislatures and courts have decided, that the subject of the diagnosis of insanity will be considered in this work. The medico-legal relations of mental derangement belong entirely to the domain of medical jurisprudence.

In beginning the examination of a person alleged to be insane, the full clinical history should, if possible, be obtained, and no point in his antecedents is altogether unworthy of notice. Inquiry should especially be made relative to the matter of hereditary tendency, the diseases the patient may have had, especially in regard to those of the brain and nervous system generally. The fact of a previous attack of insanity is an important point.

Then the occupation, habits, mode of life, natural character, and disposition should be ascertained, and all possible

data in regard to the existing accession, the time of its occurrence, the premonitory symptoms, its mode of development, and present symptoms, especially as to sleep, should be derived from some sensible person who has been in intimate relations with the patient.

Then the subject himself should be carefully examined. Efforts should be made to gain his confidence, and such questions should be put to him-guardedly, if necessary-as the previous information may suggest as most likely to cause him to disclose the present working of his mind. If the patient be an educated person, the physician will require not only a knowledge of medicine, but an acquaintance with the philosophy of the human mind, in order to conduct his examination with skill, and yet at the same time to acquire a proper degree of ascendency over the person whose mental status he proposes to investigate. Many lunatics are shrewd, intelligent, and ready to take advantage of any one whose inferiority to themselves they think they detect. The more

extensive and thorough is the general knowledge of the physician, the more readily will he obtain the influence over the patient which is so necessary to a complete examination. It is usually no very difficult task to get a lunatic to speak of his delusions, but sometimes he conceals them with a degree of obstinacy difficult to overcome. Of course, in many cases there is not the slightest difficulty in determining the insanity of a person alleged to be of unsound mind. His restlessness, gestures, play of his countenance, incoherence, mental excitement, extreme loquaciousness, betray him at once, and a lengthened examination is not necessary.

But in more doubtful cases, the perceptions, the emotions, the intellect, and the will, should all be examined into with thoroughness and exactness. The existence or non-existence of illusions or hallucinations; the sluggishness, hyper-activity, or incongruousness of the feelings; the degree of intelligence, the power of the judgment, and especially of the memory, should be tested; the ability to sustain a continuous line of thought should be ascertained; his appreciation of his surroundings, of his position in life, of his means, his whereabouts, the object of his visit, and the character of the opinions he expresses and of the feelings he reveals, should be the subjects of inquiry. In short, nothing should be omitted which may be necessary to make the physician acquainted

with the previous mental organization and present state of mind of the individual he is examining.

By an inspection of the body and its actions a great deal of valuable information can be obtained, and it is all the more useful because it is often of such a character as cannot be concealed or assumed.

First of all comes the countenance. Here the expression, as regards joy, or sadness, or stolidity, the play of the facial muscles, the movements of the eyes, the motions of the lips, the stability of the tongue when it is protruded, the presence or absence of fibrillary contractions of its muscles, the condition of the pupils as regards motility to the stimulus of light, their permanent condition of contraction or dilatation, their equality or inequality, the presence or absence of ptosis or di plopia, are all matters of importance.

Then the function of speech is capable of affording valuable indications. The character of the articulation, the ability to pronounce words with lingual or labial consonants with ease and accuracy, the degree of effort which it is necessary to make in order to articulate difficult words, the misplacing of words in a sentence, the omission of their final syllables, their clumsy pronunciation, the slurring over of words or syllables, the forgetfulness of words, are points in regard to which the examination cannot be too minute.

The gestures and movements generally which the patient may make, the degree of mobility, the sluggish condition of the body, the presence or absence of cataleptic phenomena, the actions as regards propriety and decency, the presence or absence of tremor or paralysis of any part of the body, the degree of readiness with which he responds to directions or requests to rise or sit down, to walk or to cease walking, or to put out his tongue, the position in which he holds his headwhether inclined forward in an attitude of weakness, indicating dementia or general paralysis, or thrown back in response to emotions of pride or greatness-are all to be observed.

The gestures which the feelings or passions of the patient may prompt him to make are always indications of great importance as showing the amount of power which he possesses over the expression of his passions. A man who exhibits every passing feeling which he may have, and exhibits it as he may do by an exaggerated or misplaced or incongruous gesture or action, affords some evidence of mental aberration.

The woman with erotomania puts on languishing airs, and makes amorous advances to any man she may meet. The subject of religious monomania falls down on his knees and prays without regard to the fitness of the occasion or the attendant circumstances. The general paralytic, with his delusions of greatness, speaks in a loud tone, struts about the room elevated to his extreme height, strikes his inflated chest to exhibit his strength and endurance, shows his muscular development, etc. The melancholic groans and sobs, wrings his hands, hides his face in order to conceal his tears, refuses to speak, or answers slowly in monosyllables and with evident reluctance.

ent.

Relative to the state of the viscera, the most important points are connected with the stomach and bowels and bladder. Dyspepsia, want of appetite, constipation, are often presThere may be paralysis of the bladder or its sphincter, or both. In connection with hypochondria, there may be various abnormal sensations in the thoracic, abdominal, or pelvic viscera, to which the attention of the patient is constantly directed, and to which he is anxious to attract the notice of the physician. The condition of the spinal cord and the evidences of its derangement which are supplied by the state of sensibility and motility should be carefully investigated.

The physician may be required to investigate a case in which it is suspected that the individual is feigning insanity. Persons have done this so effectually that they have succeeded in imposing on the superintendents of lunatic asylums, and in being treated as raving maniacs, the object being to observe the system upon which the institutions were managed. A very little intelligence and acquaintance with the phenomena of insanity will enable an impostor to deceive the ordinary average superintendent, who asks a few questions, and, getting incoherent answers and observing an agitated demeanor, jumps at the willing conclusion that he has a lunatic before him. There are superintendents and other medical officers of asylums, however, who, not boasting that they have never made mistakes, are nevertheless difficult persons to deceive by so transparent a fraud as that to which I have alluded, though no one, no matter how skilful an alienist he may be, is beyond the point of being imposed upon for a short time by persons assuming to have certain forms of mental derangement. An