ARTICLE IX. IMPORTANCE OF A CAREFUL EXAMINATION OF THE ALLEGED INSANE BEFORE THEIR COMMITTAL TO A HOSPITAL. BY S. B. BUCKMASTER M. D., SUPERINTENDENT OF WISCONSIN STATE "Cans't thou not minister to a mind diseased, Almost every person of the present time has a conception of insanity, though the conception is usually of an ideal and exaggerated character. During the middle ages the mind deranged was not recognized, the unfortunates so afflicted being supposed to be possessed of demons or to be witches, and many crimes were perpetrated by ecclesiastical and legal authorities in the endeavor to exorcise the demons in possession. To the people of this age, however, insanity is a real, terrorizing, ever present affliction, more dreaded than death itself, and so common in its occurrence that the family whose members to the remote branches escape its horrors is thrice blessed. Every person engaging in the practice of medicine should be prepared to deal with cases of mental aberation, as meet them he must. The mind as a form of brain energy, is studied by the physiologist, and when its manifestations become abnormal the physician must investigate it as he would a malady affecting any of the organs of the physical structure. To the members of the medical profession is given an exceptional power, by which a citizen may be deprived of all he holds dear, separated from his friends, disfranchised, debarred the privilege of controlling the property he may have spent the best years of his life in accumulating, and deprived of that prized boon- his liberty, made a prisoner when no crime has been committed. Surely with this great power at command it behooves the medical man to ponder well and carefully observe every case before a decision is made and a fellow being restrained of the privilege which is our country's proudest boast. It is assuming great responsibility to pronounce a person irresponsible, and should a mistake be made, no greater wrong could be perpetrated, or one which might re-act with more ruinous effect upon the physician making it. It is therefore of vital importance not only to the patient but to the examiner, that as clear a knowledge as possible of a malady, against which none of us can be assured, be possessed by all who may be called upon to meet and treat it. The private practitioner, usually the family doctor is the first to be called, and to him the family look for relief, or for the best solution of the difficult problem presented, and such problems are not presented infrequently. In the United States an army of 100,000 throng the highway leading into the broad field of mental alienation. At this moment at least 3,000 of our fellow citizens in the state of Wisconsin alone are insane. Nay, more; for everyone undoubtedly insane, there is probably another who at sometime has been threatened with the symptoms of insanity. What vast importance then does this subject assume! I shall not attempt to define insanity to you. I could as well define a color to a man blind from birth. As echo said to the painter: "If you must paint me, paint a voice." To quote from Dr. Maudsley, "You can no more draw a line between the physiological and pathological state of the mind, than you can draw a line between light and darkness." Dr. Crichton Browne says: "We are still as far as ever from mounting a delusion in Canada balsam, or from detecting despondency in a test tube." The line between sanity and insanity is so ill-defined that many live near it, and sometimes ramble beyond its border. The limits of a short paper will not admit of an exhaustive analysis of the etiology, diagnosis and prognosis of insanity, but I will mention a few of the most pronounced symptoms. THERE IS A DEPARTURE FROM THE NORMAL CONDITION OF THE INDIVIDUAL. The generous man becomes miserly, the cheerful companion becomes morose or suspicious, the sedate, dignified gentleman or lady may become vulgar and obscene. The individual may have delusions or hallucinations, and, his defective reason prohibiting his cor recting these false perceptions, he accepts them as true, though this condition of mind may entirely escape the observation of all except his most intimate associates. THE INSANE MAN IS NOT IN HARMONY WITH HIS SURROUNDINGS. His occupation may be most menial, yet his excited imagination. makes him the possessor of great wealth; he is a presidential candidate, or even the Creator. This inconsistency is daily witnessed in every hospital for the insane, particularly in cases of general paresis, I recall a patient who was at the state hospital for years. A man of boundless wealth, whose horses could trot a mile in two minutes and who proposed to rebuild Alexandria after its bombardment, as it would cost but seventy-five trillions of dollars! Yet this patient for years was perfectly happy in his work at the engine house, where penniless and begrimed he failed to see the inconsistency of his claim. Another who labored for years at the laundry, claimed to have lived at the hospital five thousand years before the sun was created, and who possessed such a large pile of silver that he could ride in its shadow at noon. These patients were not in accord with their environments. What is equally surprising is that patients frequently recognize and ridicule the delusions of others, while expressing their own. I was once stopped by a patient who expressed a delusion that was promptly combatted by another, who immediately proceeded to tell about the three rattlesnakes inhabiting her head. Do not think, however, that all the cases that may present themselves are as pronounced as the ones I have used in illustration. A popular fallacy among the laity is that every insane person must be a raving maniac, though nothing could be farther from the truth. Many times the examiner will be perplexed, and may even think that relatives have sinister designs in declaring a person insane, whose carefully guarded conversation and action gives no immediate suggestion of mental ailment. We sometimes hear it said that patients are committed to the hospital by relatives who seek to secure their property, or from other malicious motives. To the credit of our profession I wish to say that in a residence of over eight years in the state hospital for the insane I have not known one case to be committed where there were not some symptoms of insanity. Mistakes are made, but the patient if not insane is delirious, hysterical, drunk, a dotard or a case of congenital mental defect. Sane persons are not maliciously com. mitted to hospitals for the insane. In many doubtful cases only close and repeated observation and questioning will elicit the desired information. I venture to offer a few suggestions in regard to making examinations. It is not essential that the alleged insane person should always know the object of your visit, yet deception should always be avoided. Learn what you can from friends before seeing the patient, and use the information thus gained in your conversation with him. Especially in your consultation with friends should you dwell upon the question of heredity. Friends will frequently conceal the fact of its existence, with the idea that it is a disgrace upon the family. A very large per cent. of cases of insanity occur in patients inheriting the tendency-a certain mysterious instability of the cortical cells-from ancestors. Dr. Maudsley in his "responsibility in mental disease" says, "there is a destiny made for a man by his ancestors, and no one can elude, were he able to attempt it, the tyranny of his organization." This assertion is probably too sweeping, as education, association, etc., may exert a materially modifying influence. Do not be too hasty in filling out the commitment blank, as reliable statistics depend upon the accuracy with which this is done. Inquire as to any change in the character of the individual, as to the presence of hallucinations or delusions, though the long established legal maxim that the latter must always be present to constitute insanity is not true, as many cases exist without them. Note the patient's temperature. If this were always done, some cases that enter the hospitals and add to their death rate by dying of meningitis or in the delirium of fever, might have recovered at home, or spent their last hours surrounded by their relatives and friends. I regret to say that some persons seem anxious of being relieved of the care of their aged parents or grandparents, who as they approach their dotage are more or less troublesome, and for that reason the relatives who should care for them seek to commit them to the hospital. Of 250 cases admitted to the state hospital in 1887 88, 15 per cent.—were over 60. Of 29 deaths during 1887 out of a total of 783 treated, 5 were between 60 and 70 and 5 were over 70. Within in one week, some two months ago, we received an old lady of 88 and a man of 90. It is a sad commentary upon filial affection. But the fact is that many of these cases are not so troublesome but what they could and should be cared for by their relatives at home. Find whether there is any interference with the function of sleep, as is usually the case. Determine whether the bodily functions are properly performed. In many cases it will be found that constipation exists, while with many female patients, menstruation is not normal. Inquire whether patients ever had any previous attacks and if so how many, their duration and where treated. Ascertain what cause the relatives assign, and whether the patient ever received an injury to the head, had a sunstroke, or suffered from epilepsy or any nervous affection, and satisfy yourself as to the presence or absence of any complicating disease. Let me further ask that you ascertain whether the alleged insane males were in the army during the rebellion, and if so, whether their friends attribute. their present disability to said service. This is a subject rarely mentioned in commitment papers, yet almost every week friends apply to me to aid them in securing a pension, and the department at Washington asks for a copy of the commitment papers in which it may not even be mentioned that the patient was in the army. Most of the above points are suggested in the questions asked in the commitment blanks. You can do much to aid in dispelling the unreasonable and unjust prejudice existing against hospitals for the insane in some communities-a prejudice that works injury to many who are kept at home, until the favorable time for treatment is past. Impress upon relatives the fact that for years past at the state hospital, and the same thing is true of other hospitals, that of those who have been insane three months or less almost one half recover, and many of the others greatly improve, while of those insane much over one year few recover. A great responsibility rests upon those who in any way aid in depriving the insane of the right to early treatment. Remember that most of the stories circulated about hospitals for the insane, originate with discharged employes who seek to justify themselves in the eyes of their friends, or in the statements of discharged patients who though recovered may remember a delusion as something that actually occurred. Sensational, unsustained newspaper articles do incalculable injury. Patients are kept at home by relatives who read these articles, until the favorable time for treat |