6. Remember there are three aspects to every case of insanity-the medical, which concerns you as a physician about to treat a patient; the medico-legal, which concerns you and the patient in regard to depriving him of his liberty and of the control of his affairs, and affects his responsibility to the law; and the medico-psychological, which includes all the mental problems that arise in a study of the case.

7. Always pass before your minds the following conditions, and by exclusion determine that the case is not one of them, viz., drunkenness, drugging by opium or other narcotics, meningitis, cerebritis, brain syphilis, the fevers, sunstroke, traumatic injury to head, hysteria, the cerebral effects of gross brain diseases, simple delirium tremens, the temporary cerebral effect of moral shock, or the delirium that precedes death in many diseases and in old age. I have had cases of drunkenness, meningitis, typhus and typhoid fevers, hysteria, apoplexy, delirium tremens, and the delirium preceding death, sent into asylums under my care, as laboring under ordinary insanity, and have heard of the other conditions being so mistaken. Many of these conditions and diseases may, however, lead to, or be associated with, real mental disease, and require treatment as such.

8. In the clinical study of mental diseases, try and look on all the abnormalities present, mental and bodily, as being symptoms of the disease, and essential parts of the brain disturbance present, and not as mere accompaniments. For instance, in a case of puerperal insanity, it is not merely the delusions and mental exaltation that are the disease, but the high weak pulse, the raised temperature, the glistening eye, the constant muscular motion, the dry tongue, the uterine tenderness, the absence of lochia, the sleeplessness, the paralysis of appetite, are all symptoms of the disease in a true sense- —that is, they are all results or essential concomitants of the brain disturbance, of which the mental symptoms are the most striking features.

9. The patient's account of himself is not always to be relied on. He may be dying, and yet to his consciousness have no symptom of it, so that he tells you he never was better in his life; his bowels may have been moved freely that morning, and yet he tells you he has not had a motion for a week; he may not be able to write a line, yet he says he never wrote so well in his life, etc. You must, through your reasoning, medical examination, and observation, find out what is true and what is delusion. I had once a case where a medical man certified as a delusion what an examination would have shown him to be a fact, viz., that the patient was pregnant. Certain things of the greatest import in a case of insanity the patient is very apt to deny, such as suicidal feelings, masturbation, etc.

10. It may be needful in some cases for the patient's safety, or that of his relations, or for the preservation of his property, to practise some amount of concealment of your profession, and of the object of your visit. The man knows so well what a doctor's visit means that he will not see a doctor if he knows him to be one, or he is so dangerous and cunning that needless risk would be run by announcing to him the object of your visit. But the public and the friends of patients have often a most

needless desire that you should practise guile where there is no necessity in the world for it. As a general rule, there is not much to fear from the insane of the respectable classes of society. But cunning and suspicion are the marked characteristics of many of those affected in mind. 11. Negative symptoms-silence, obstinacy, stupidity, etc.-are to be noted and are valuable in diagnosis and treatment.

12. Compare mentally the man as you see him with the man you may have known or had described to you.

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13. The chief questions you ask yourself, and the main problems that you have to solve, are the following: Is the man mentally affected or not? If so, is he sufficiently affected to be regarded as legally insane and irresponsible? What form of insanity does he labor under? Can the brain disease be localized or its pathological character determined? What is to be the treatment? What risks are there in the case, e. g., suicide, danger to others, convulsions, paralytic attacks, exhaustion, refusal of food, or sudden death? What is the general prognosis? How long will it be before the case recovers or dies? Is home treatment suitable or safe? or must the case be removed from home to the country, or to a hospital for the insane? Can trained reliable attendance be got? What mental therapeutics must be adopted, cheering or soothing, diverting, reassuring, checking, agreeing with him, contradicting him, or avoiding his favorite topics?

14. It is always well, in a case of mental disease, to make the relations. or guardians of the patient very fully acquainted with the risks of the case, to keep them hopeful if there is any hope, to give the patient the benefit of all doubts, to guard yourself in prognosis, remembering that our knowledge of mental disease is imperfect, and that the most experienced of us are deceived sometimes, and that there are few rules in regard to brain disorders to which there are not exceptions, to take no more responsibility about sending a patient to an asylum, for instance, than fairly can be laid on a medical man, making the relatives take their proper share. It is, as a general rule, better not to be too explicit about the time it may take a patient to recover. If you undertake the treatment at home, or in a private house, only do so on the understanding that the nurses or attendants are under your exclusive orders. If you have to sign a certificate of insanity for placing a patient in an asylum, or taking the management of his affairs out of his hands, remember there is often a legal risk to yourself from the patient bringing an action against you, a risk that in some rare cases it is well to avoid by even getting a letter of indemnification from a relation before you sign it.

15. In regard to the question of home or asylum treatment, it depends on many other things as well as the patient's condition. His means are the first of these. Home or private house treatment of a case of mental disease is mostly expensive from the skilled attendance needed. In the midst of a city, home treatment of almost any case is most difficult. Home treatment is often impossible from the associations and surroundings aggravating the disease. If there is a very intense suicidal tendency, the risks cannot well be obviated in a private house. If there is noise, maniacal excitement, or constant muscular motion, a private house is

seldom a proper place for long. In a good hospital for the insane, most of the means of treatment, safety, skilled attendance, regular exercise, a proper mode of life, the administration of food and medicines, can no doubt be best attained, but then there are the counterbalancing disadvantages of the harm to the patient's prospects, from the cruel popular prejudices about asylums, and the patient's own feelings about it afterwards. If you can treat a case out of an asylum, and he recovers satisfactorily, it is better for you and him.

LECTURE II.

STATES OF MENTAL DEPRESSION-MELANCHOLIA (PSYCHALGIA). ALL the morbid states of depressed feeling, or, as more commonly expressed, of mental depression, are comprised under the term Melancholia. Like the other symptomatological varieties of mental disease, melancholia does not admit of an absolutely precise definition. In every case there must be mental pain, hence I have suggested as an alternative the term Psychalgia, but then mental pain does not alone constitute melancholia. As man's experience goes in the world at present, mental pain scarcely implies the idea of disease at all. The causes and occasions of mental pain from within and without are so common, as most men are now constituted and situated, that its presence is the rule with many, and its entire absence the exception with most. To constitute melancholia there must be disorder of brain function. A man's finger is squeezed in a vice, and he feels the most intense pain, but we do not call that neuralgia. He loses a child or a fortune, and feels intense mental pain, but we do not call it melancholia, because there is no disease. All brain reactions mentally in obedience to adequate causes are simply the exercise of physiological function, but when the reaction is quite out of proportion to the cause, or when the exercise of the activity of the brain induces mental pain of a certain intensity and kind without any outside cause, then we conclude that the mental portion of the organ is disordered, and we say that the patient suffers from melancholia. There may be in the case certain excitants wrongly called causes-mental, moral, or physical. The man may have committed crimes, or he may have a badly acting liver, or he may be very anæmic, and all these things may cause mental pain and depression in a healthy brain, but they will not cause them in that amount and kind to constitute melancholia till his brain convolutions have taken on a disordered action-until their dynamical state is that of disease, not that of health. If a man's heart is depressed in its action from a fright, we do not give this a name implying disease, unless the depression goes on long after the cause has ceased to act. This illustrates, too, the weak points of the method of classifying mental diseases from mental symptoms alone. It is as if in cardiac diseases we should classify them as syncopes, palpitations, and anginas. Therefore, we must always keep in mind, in using such terms as melancholia, that the mental symptoms are not the discase; we must always consciously refer those symptoms to the brain convolutions in the diagnosis and treatment of mental diseases, which are simply brain disorders of different kinds in which the mental symptoms predominate. In assigning causes, we may say that peripheral irritations, anæmias, and moral and mental shocks have caused the disease; but we must clearly keep in mind that the

mental symptoms of the disease are caused by the disordered working of the encephalic tissue. If that remains sound in structure and working, no amount of anæmia or moral shock will cause any real mental disease. States of mental depression are, in some of their forms, of all mental diseases those that are nearest mental health. They shade off by imperceptible degress into mere physiological conditions of mind and brain. To be able to feel ordinary pain implies an encephalic tissue for the purpose. To be very sensitive to pain implies that the tissue is acutely receptive of impressions. So with mental pain there can be no doubt that the healthy physiological condition of the encephalic tissue in the brain convolutions through which ordinary or mental pain is felt is one between extreme callousness to impressions and extreme sensitiveness. A man in robust health, well exercised, does not feel pain nearly so acutely, and bears it better than when he is weak and run down. Those principles apply equally to the feeling and the bearing of mental pain. To experience emotion at all-to feel-implies an encephalic structure for this purpose. The most casual study of the affective capacity in human beings shows us that it differs enormously in different persons. One man will lose his children or his fortune, or see the most terrible sights, and he will not feel keenly at all, because his brain convolutions. that subserve feeling are not in their essential nature very receptive and sensitive. Another person will be thrown into very great grief, and feel acute agony, at the loss of a favorite dog. I had a lady patient once, A. A., who would be for days depressed, and suffer mentally, if a friend did not receive her as cordially as usual any day. She suffered mental torture if a relative spoke sharply to her, and she was absolutely paralyzed in feeling and volition by the death of a sister. She had several attacks of mild melancholia produced by most inadequate causes, from all of which she recovered quickly and completely. There can be no doubt whatever that the finer moulds of brain are mostly very sensitive, and the poetic, emotional, and sympathetic natures have always been subject to states of painful depression of mind at the critical periods of life, and when the physical vigor was below par. Half the poets and men of literary genius give ample proof in their writings, and in the characters they have created or founded on their own experience, that they suffered at times intense mental pain. Goethe clearly looked on a period of melancholy as one phase in the development of genius. The lives and writings of Goethe, Schiller, Carlyle, Cowper, John Stuart Mill, Byron, Burns, and George Elliot show that they all had periods in their lives when they suffered intense mental pain, and at least one of them did actually pass the undefined borderland that separates physiological mental depression from pathological melancholia. To feel intense mental pain is mostly the necessary accompaniment of the capacity to feel intense joy. The brain qualities that give intensity to the one give also intensity to the other.

We must take into consideration in every case not only the sensitiveness and the receptivity, but also the power of bearing pain-the inhibitory power against pain. Some brains possess great sensitiveness and also great power of inhibition. Those are the strong brains, even though their temperament and diathesis may handicap them. But when