Lecture Vii.

THE NATURE OF INSANITY.

The subject of the present lecture, gentlemen, is "Insanity."

I. This subject belongs to a course of Medical Jurisprudence, because a physician who treats patients for insanity is liable, from time to time, to be cited before a court of law either as a witness or as an expert. His conduct in such cases is to be guided by the principles of natural and legal justice.

Various important cases at law turn upon the question of a person's soundness of mind; and frequently the medical expert has it in his power to furnish the court with more reliable information in this matter than any one else. At one time, the validity of a last will may be contested, and the possession of a fortune by one party or another may hinge on the question whether the testator at the time of making his will was in sufficient possession of his mental powers to perform an act of so much consequence.

At another time, interested parties may plead for or against the validity of a sale or other bargain made by a person of doubtful competency of mind; or a life-insurance company may be interested in ascertaining the mental condition of an applicant for membership; or it may be questioned whether the payment of an insurance policy is due to the family of a suicide, the doubt depending for solution on the sound or unsound condition of his mind at the moment of the fatal act. Again, there may be a real or pretended doubt whether a certain property-owner is so far demented as to be unfit to manage his estate; or whether he needs a guardian to take care of his person; or it may even seem necessary to confine him in a lunatic asylum. There may be objections raised to the mental soundness of a witness in a civil or a criminal suit; or, finally, a criminal prosecution will depend mainly on the sanity or insanity of the culprit at the moment when the crime was committed; as was the case with a Prendergast and a Guiteau.

You see, then, gentlemen, that important interests are dependent on the thorough and correct understanding of this matter; and therefore much responsibility rests upon the experts consulted in such cases: property, honor, liberty, nay, even life itself may be at stake.

That cases involving an insane condition of mind must be of frequent occurrence, both in the medical and in the legal professions, is apparent from the large and rapidly increasing amount of lunacy in our modern civilization. Wharton and Stillé's "Medical Jurisprudence" states (sec. 770, note) that in 1850 there was in Great Britain one lunatic to about one thousand persons; only thirty years later the Lunacy Commission of Great Britain reported one lunatic to 357 persons in England and Wales, that is, nearly three times as many. In New York there is one to 384 persons. It appears certain that its increase of late is out of all proportion to the increase of population; and even though I see reasons to distrust somewhat the figures quoted for England, enough is known to create serious alarm regarding the fruits of modern manners and customs on the minds of thousands. This fact makes the matter of insanity very important for the medical and the legal student.

II. Still it must be noted that the responsibility of deciding cases of lunacy does not rest chiefly with the medical expert. In cases of doubtful insanity the decision is to be given not by the Doctor but by the court of justice. Except on very special occasions, as when a physician is appointed on a committee or commission of inquiry, he appears before a court either as an ordinary witness, stating what facts have fallen under his personal observation; or as an expert, explaining the received opinion of medical men with regard to cases of a certain class. Even though he feels convinced that the culprit or the patient is as mad as a March hare, the physician cannot expect that his statement to that effect will be received as decisive. It is for the judge to instruct the jury what kind or degree of insanity will excuse a culprit from legal punishment, or will disqualify a person from testifying as a witness, or from being a party to a civil contract in certain cases; and it is for the jury to decide whether, in the case in hand, the fact of such insanity exists or not. In criminal cases, the jury pronounces on the double question, whether the accused did the act charged to him, and whether he has been juridically proved to have been accountable for the act under the laws as expounded by the judge.

1. To come to a decision on this double question, the jury might need to hear the facts stated which the physician has personally observed, and of which he is summoned to be a sworn witness. In such a situation all that is required of the Doctor is that he shall give a most faithful and intelligent account of the facts.

It would disgrace his standing in society if any fault could be found with his testimony; and, as a sworn witness, he is bound in conscience, like any other witness, to state the truth, the whole truth, and nothing but the truth. This is always the case when the purpose of the inquiry is the discovery of the sane or insane condition of a person's mind. But if the inquiry concerns the performance of the guilty act, the commission of the crime, many States of the Union, as explained before, consider the Doctor's professional secrets as privileged, just like those of the lawyer and the clergyman; i.e., the Doctor must not use against his patient any knowledge he has become possessed of while acting as his medical adviser.

2. When the physician appears before a court or commission as an expert, he is expected to give the views of the medical profession upon hypothetical cases resembling the one under examination, and the scientific reasons and authorities on which those views are advanced.

3. But here a considerable difficulty presents itself; it is so serious that, owing to it, the weight of the medical expert's testimony with judge and jury is often much less than could reasonably be desired. The difficulty is to ascertain what really are the views of the medical profession on any given subject. Of course no individual Doctors can put themselves up as representing the convictions of the medical profession, nor can they always appeal to the unanimous agreement of their leading men. Leading physicians, unfortunately, are far from entertaining concordant views on many most vital questions. It is this want of agreement that has made the testimony of experts so powerless to sway the minds of judge and jury.

The medical profession has no organization through which it can pronounce judgment. In fact, many of its most conspicuous members have adopted principles at variance with the deepest convictions of mankind generally; such, for instance, are the followers of Darwin, Huxley, Maudsley, and similar agnostic and materialistic leaders of modern thought.

4. What still further diminishes the credit of medical experts is the fact that, both in civil and criminal trials, they are summoned either by the defence or by the prosecution, and are thus naturally selected, not on account of their thorough knowledge, but on account of their peculiar views known beforehand to the parties citing them. Thus their testimony is likely to be partial to either side, and is distrusted; at least it fails to command perfect confidence. The only way in which the prejudices thus created against the physician can be overcome is by his acquiring thorough knowledge of his specialty, and showing himself on all occasions to be as honorable and faithful as he is evidently experienced and intelligent.

5. The medical profession could be brought to be much more useful to society for the discovery of insanity if we could have here something like what exists in some parts of Germany. "The practice obtains there of requiring the medical faculty of each judicial district to appoint a special committee, to which questions of this kind are referred. This committee is examined directly by the court, and gives testimony somewhat in the same way, and with the same effect, as would a common-law court when reporting its judgment in a feigned issue from chancery, or as would assessors called upon under the canon law to state, in proceedings under the law, what is the secular law of the land on the pending question" (Wharton and Stillé, sec. 274).

The matter of introducing some such practice into this country has been agitated of late, and may by and by lead to beneficial results. Dr. Shrady has taken steps to promote this object by striving to have a law enacted by the New York legislature providing for the regulation of expert medical testimony in jury trials. According to his plan, once such a commission has been established, the court is to send the medical issue to these experts, just as it sends other issues to special juries to be decided. The regular petit jury will then decide only upon the facts constituting the crime.

This would do away with special pleas of insanity before a jury that knows little or nothing about the nature of the disease, and whose sympathies may readily be worked upon by shrewd lawyers to render a verdict of acquittal.

As things are now, the medical expert, summoned to testify in a case of contested sanity or insanity of mind, ought to rise above minor considerations, and promote the cause of justice, by giving all the valuable information that his profession enables him to acquire on the very difficult subject of mental unsoundness.

6. For this purpose, he must be skilled in three departments of science.

(a) In law--sufficiently to understand what are considered by the courts as characteristic marks of an insane mind, and what amount of sanity the courts require to hold a culprit responsible for his crime or a contract valid in its effects.

(b) In psychology--to such an extent that the expert witness can speak analytically and correctly as to the properties and actions of the human mind.

(c) In medicine--so far as concerns the treatment of the insane, and the understanding of their peculiarities, so as to reason from them by induction to the real condition of the client's or patient's mind.

But the main requisite for an expert witness is to understand clearly in what insanity properly consists, and how far it ought to excuse an insane man from bearing the consequences of his acts.

III. This two-fold knowledge is obtained by the psychological study of insanity, on which study we are now to enter, and it is the principal point in this whole matter.

Insanity means a want of soundness; he is insane whose mind is not sound, but is deranged, and therefore, like a machine out of order, it cannot properly perform its specific task, namely, to know the truth of things. An insane man cannot judge rightly.

1. Insanity takes various forms, which may be reduced to two kinds, with the doubtful addition of a third kind, namely, moral insanity, of which we shall speak in our next lecture.

The first kind consists in the total want or gross torpor of mental activity. When there is a total, or nearly total, eclipse of the intellect, the disease is called idiocy, the state of an idiot. When there is an abnormally low grade of the reasoning power, it is styled imbecility. The failure or decay of reason in old age is called dotage.

The second kind of insanity is called illusional or delusional. In it the intellect is not impotent; on the contrary, it is often unusually active; but its action is abnormal, its conclusions are false. Not that it reasons illogically or draws conclusions which are not contained in the premises. Very keen logicians may be demented. Their unsoundness arises from the fact that they reason from false premises; and they get their false premises from their diseased imaginations, whose vagaries they take for realities.

2. Here a difficulty presents itself, which we must explain at once, namely, how can there be unsoundness of mind at all? Is not the intellect of man a simple power, and his soul a simple being? How can a simple being become deranged? Can that which has no parts become disarranged, disorganized? I answer, the soul is a simple being, its intellect is a spiritual faculty; and therefore we never say that the soul is insane, nor should we say that the intellect is insane or diseased; but we say that the mind is deranged or insane; the mind comprises more than the intellect; it designates the intellect together with those lower powers that supply the materials for our thought, the chief of which is the imagination. Now the imagination is an organic faculty: it works in and by a bodily organism, which is the brain. Therefore, when the brain is not in a normal condition, the action of the imagination may be disordered. And the intellect or understanding of the spiritual soul is so closely united in its action and its very being with the organic body that the two ever act conjointly, like the two wheels of a vehicle. If one wheel breaks down, the other is thrown out of gear. Thus it is readily understood that mental unsoundness is an affection of the brain, a bodily disease, which may often be relieved and even cured by bodily remedies, by the use of drugs or wholesome food, healthy exercise, fresh air, and all that benefits the nervous system.

Pathologically considered, the nerves may be too excited or too sluggish and torpid; and we have as the result two subdivisions of mental insanity--mania and melancholia. The differences between these two are very striking; as they proceed from opposite causes they produce opposite effects, and, therefore, they betray themselves by very different manifestations; but in one point the two agree, and with this point precisely we are concerned, because in it lies the essence of mental insanity, namely, that both produce a disordered action of the imagination.

3. The manner in which the imagination co-operates in mental action is this. It presents to the intellect the materials from which that power forms its ideas. When we see, feel, hear, taste, or smell anything by our bodily senses, our imagination takes note of the object perceived by forming a brain-picture of it which is called a phantasm. I do not mean to say that it forms a photographic picture of the object; for there can be no photographing taste or smell or feeling; but it forms an image of some kind which it presents to the intellect. This power at once proceeds to form, not a brain-picture, but an intellectual or abstract image of the object presented. For instance, you see this book, and at once you, in some mysterious way which has never yet been explained, impress some image of it on your brain. That you do so is clear from the fact that the image remains when the book is withdrawn. That material image or brain-picture is the phantasm. It is not an idea, though it is often improperly so called. But your intellect forms to itself an idea of a book; that is, you know what is meant by a book. You distinguish between the mere form of a book and the book itself. Your idea of a book is a universal idea, which stands for any book, no matter of what shape or size. Every phantasm, or brain-picture, is a representation which presents its object as having a definite shape or size, while your idea of a book ignores any shape or size. And yet, when your intellect conceives a book, your imagination will picture some particular form of book. If your brain became so affected by disease as to be unfit for the formation and retention of the proper phantasms, then your intellect either would not work at all or it would work abnormally; your mind would then be insane.

4. Now, in an infant the brain is still too soft and imperfect to form the proper phantasms from which the intellect is to elaborate its ideas. A false school of psychology would say that the infant's brain cannot yet ideate; but that is incorrect language. No brain can ideate or form ideas; an idea is an intellectual or mind image, not a brain image; it is an abstract and universal image, and matter cannot represent but what is concrete and individual. Only a simple and spiritual being, the rational soul, can form ideas. Nevertheless our soul, in its present state of substantial union with our body, is extrinsically dependent on the body; to form ideas it needs to have the sensible object presented to it by a phantasm or brain-picture. Now, a child born blind and deaf, and thus having its mind, as it were, cut off from communication with the outer world, could scarcely form the necessary phantasms, because the clogged senses could not supply proper materials for them; such a child would, therefore, be apt to remain idiotic. And even in children whose outer senses are sound the brain or the nervous system may be too imperfect to allow of its forming proper phantasms. In this torpor of the mind then consists the first kind of mental unsoundness, that of idiocy, or its milder form imbecility. In old age, and in peculiar diseases, the worn-out system may return to a second childhood, then called dementia or dotage. The existence of such species of insanity is not difficult to discover.

5. The second and more common form of insanity, and that which it is often difficult to discover and pronounce upon with certainty, is that which I have called delusional or illusional. Its characteristic trait, its very essence, lies in this, that the insane man mistakes what he imagines for what is real; and he cannot be made to distinguish between imagination and reality, though the difference is obvious to an intellect in its normal state.

In this connection, it is well to point out a distinction, not always observed, but useful to explain the workings of an insane mind, between illusions, hallucinations, and delusions.

(a) An illusion is properly a deception arising from a mistake in sense-perception; as when a half-drunken man sees two posts where there is only one. He has a picture of the post in each eye, and his brain is too much disturbed to refer the two pictures to the same object. In this case the cause of the mistake is subjective. A mirage offers another instance of a sense-illusion; but in it the cause is objective.

(b) A hallucination is a creation of the fancy mistaken for a reality. The deception may be but momentary, as when Macbeth is stealing on tiptoe to the chamber of his guest to murder him. His mind is disturbed by the imagination of the horrid deed he is about to perpetrate. He thinks he sees a dagger in the air, and he says: "Is this a dagger that I see before me, its handle towards my hand? Come, let me clutch thee. I hold thee not, and yet I see thee still; and on thy dudgeon gouts of blood, which was not so before." But Macbeth, upon a moment's reflection, sees it is all imagination. "There's no such thing," he exclaims. He is not insane, though deceived for a while.

(c) A delusion, on the contrary, is a permanent deception, whether it results from an illusion or a hallucination, it matters not; as a fact, it almost always originates in hallucinations. The deluded man clings to his imaginings; you cannot talk them out of his head. Such is the case of an inebriate who suffers from mania a potu, or "the horrors;" he sees snakes and demons, he thinks, and persists in his error. Such also is a fixed idea not arrived at by faulty reasoning, but come unbidden and proof against all reasoning and evidence. Thus an insane man may be convinced, solely by his imagination, that he is poisoned or pursued or conspired against.

6. This delusion constitutes the essence of mental insanity, which therefore is often called delusional insanity. It may be chronic, i.e., of long continuance, or it may be temporary, acute. For the time being, the effects are the same. Perhaps any man may, at times, be for a moment thrown off his guard, and mistake a fancy for a reality; this does not constitute lunacy. But when the error is so firmly held in the mind's grasp that nothing can dislodge it thence, then the mind is deranged in its special sphere of action, which consists in knowing the real from the unreal; the mind is then insane.

You notice, gentlemen, that I speak of the mind as grasping the error, and I suppose it to do so independently of the free will's command. But when the error is voluntary; when a man clings to it simply because he loves it; when he hugs a delusion to his heart, this shows not mental but moral obliquity; it is not insanity but self-deception, and it is by no means of rare occurrence. In a well-reasoned article on "The Metaphysics of Insanity," written by Mr. James M. Wilcox and printed in the "American Catholic Quarterly Review" for January, 1878, some very severe and no less true strictures are made upon the readiness of a vast multitude of people to practise this wilful self-deception. "Self," he writes (p. 54), "is the prolific origin of such errors; and so indulgent are we to its faults that we try secretly to hide them even from our own eyes, mostly with success; and where success is not perfect, we make a second effort to hide the imperfection. Repeated efforts of this kind, from which we but half turn away, are crowned in the end, and we soon forget what successful hypocrites we have been. Our numerous passions, the complexities of our desires, the tenacity of their grasp, and the pleasant gentleness of its touch explain an infinity of temptations followed by wilful successes in blindness, all of which are nothing less than guilty acts of self-deception."

7. It oftens happens in real insanity that mental derangement manifests itself upon one error or one group of errors only, while for all the rest the patient appears to be quite rational. Such a man is called a monomaniac. But he is truly an insane man; for the essence of insanity is in him. It is usually found that a monomaniac will, sooner or later, exhibit signs of mental unsoundness on other matters as well; and even while he has given no such signs, it still remains true that a mind cannot be trusted, but has something radically unsound about it, if it is really unhinged at any point at all.

But then you must be very careful not to confound monomania with eccentricity. The distinction is as important as it is real. Eccentricity is a conscious aberration from the common course of life; it consists in peculiarities in reasoning, words, and actions, which are wilfully indulged, in defiance of popular sentiment. The eccentric man knows that he is eccentric; he is willing to be so, and to take the consequences; but he is not insane.

As this matter is of frequent occurrence before the courts of justice, and the validity of last wills in particular often depends on the view that judges and expert witnesses take of it, I think it well to refer the earnest student for further information to Wharton's and Stillé's "Medical Jurisprudence," in the volume on "Mental Unsoundness and Psychological Law;" in particular to secs. 29, 38, 39, 40.

8. We must now return to the consideration of the manner in which the disturbance of the brain may affect the mind. The brain is a storehouse of records of things formerly noted there by the imagination, either as the results of sense perception or of arbitrary combinations of phantasms; it is a library of facts and fancies. And these are not single, but grouped together, so that when one is stirred it will arouse others as well. When the brain is affected, whether by an acute or a chronic derangement, its images may become so disordered that records of mere imaginations get mixed up with records of real perceptions in inextricable confusion. You may have had occasion to notice the process in the case of a man who is becoming intoxicated and then passes on to mania or delirium tremens: he gradually proceeds to mix up brain-pictures with realities, and after a while he speaks and acts like a very crazy man. He is in a kind of dream; his imaginations are wild and disconnected, his language is incoherent.

The delirium arising from violent fevers, for instance from typhoid fever, is very similar to that arising from the excessive use of intoxicants and narcotics; similar in these respects; that the mania is only temporary, and that the exciting cause is not altogether unknown.

The bacilli of the infection, like the alcohol, the opium, the morphine, or other drugs, are accountable for the disordered action of the brain. But I do not pretend to know, nor do medical writers generally pretend to understand, how the poison, or whatever causes the disease, gets to affect the brain. Does it do so directly, or by means of the alteration it causes in the whole nervous system or in the blood? We do not know; nor does it matter for the purposes of Medical Jurisprudence.

IV. The questions with which the courts of justice, the lawyers, and the expert witnesses are concerned are these: Is the man really insane? Or was he insane at a given time when he performed a certain civil or criminal act? Is he now, or was he then, so far controlled by his mental unsoundness as to be incapable of acting like a rational being accountable for his actions? Even if he is now, or was then, a monomaniac, can the deed in question be traceable to his monomania as to its real cause?

1. When we know that a man is suffering from a fever, or has been drinking to excess, or has been addicted to the use of morphine, opium, cocaine or to similar deplorable practices, it is then easy enough to conclude from this that he is not in his right senses; knowing the cause, we can fairly estimate the effect. But in many cases of delusional insanity the cause is hidden; neither pulse nor other medical test betrays it. Whether the mind is sane or not is then to be found out from the man's words and actions; and these may be affected for a purpose: he may play the fool to escape punishment.

2. Phrenologists have pretended that the peculiarities of a person's mind could be known by the conformation of his brain, and even by the elevations and depressions of the skull. But brain and skull do not always correspond with sufficient closeness; and besides, Sir William Hamilton has shown conclusively, I believe, that phrenology is quackery; its principles are not scientific and its observations not reliable. He points out, among other errors, that while women as a class are more religiously inclined than men, what phrenologists call the bump of reverence, an important element in religious sentiment, is generally more developed in men than in women, and is often most conspicuous in reckless criminals.

Nor is it at all certain that a lunatic's brain, if it could be examined with a microscope while he is alive, would exhibit the marks of any disorder to the eye of the observer. It is stated by Dr. Storer that the results show that "insanity may exist without structural changes of the brain, and that structural changes in the brain may exist without insanity." Dr. Bell, of the Somerville Asylum, says that "the autopsies of the insane generally present no lesion of the brain." Dr. Bucknil maintains that "the brains of the insane appear to be certainly not more liable than those of others to various incidental affections." Nor has the microscope discovered in the demented any exudation or addition to the stroma of the brain, or any change in size, shape, or proportional number of its cells. Dr. Storer concludes: "It is thus seen not merely that there is no direct correspondence between the exterior of the skull and mental integrity, any more than between the exterior of the skull and the shape and consistence of its contents" (Wharton and Stillé, "Mental Unsoundness," sec. 323). In the cases of insanity among women, the causes are largely to be found in derangement of their productive organs, and are to be met by special local treatment (ib.).

It does happen, however, at times, that the brain itself is diseased, idiopathically diseased, as it is technically called; but at other times it is merely affected by sympathy with some other organ that is physically deranged. A physical cause there is for all mental insanity, and that physical cause determines its kind of mania or melancholia, its duration, its chances of a perfect cure. But what that cause is in a given case is often very hard if not impossible to determine. Besides natural and inherited predispositions--some taint of derangement in the family, often betrayed by fits of epilepsy, hysterics, etc.--exciting causes are usually traceable. Every form of disease may bring on sympathetic affection of the brain when the circumstances for such affection are favorable.

But while affirming that the disease usually arises in the body, and even frequently in parts far removed from the brain, we must not deny nor ignore the fact that intellectual and protracted worry, or sudden and violent grief, can also be the direct cause of disturbance in the brain. For the brain is the organ not of the imagination alone, which is put to an unhealthy strain by excessive mental labor, but probably also of the passions, whose emotions when excessive may cause even permanent lesion. Hence mental insanity may and does often arise from ill-subdued passions.

The knowledge of all this may enable the physician to remove the exciting cause or to mitigate its influence; it may also aid expert witnesses, judges, lawyers, and jurymen to ascertain the main fact with which the courts are concerned, namely, the presence or absence of mental insanity at the time of a given civil or criminal action.

V. Supposing then that, in the case before the court, the fact of insanity is established, the next question of Jurisprudence to determine is this: How far and why ought such unsoundness of mind to exclude responsibility for deliberate acts?

It is a clear principle of reason that no man can justly be blamed or punished for doing what he cannot help doing; now an insane man cannot help judging wrong at times; he cannot then justly be blamed for acting on his mistaken judgments. If he invincibly judges an act to be morally good whereas it is morally bad, no matter how criminal the act may be--say the killing of his own father or child--if he commits the deed with the full conviction that he is doing right, he cannot be blamed or punished for committing that awful crime.

The principle then is clear that an insane man is not to be held responsible to God or man for his insane acts. For the root and reason of our responsibility for an act lies in the fact that we do the deed of our own free choice; knowing its moral nature, being masters of our own free will, so that, if we do one act in preference to another, we wilfully take upon ourselves the consequences of this preference as far as we can know or suspect them.

If we do what we are firmly convinced is right, just, worthy of a man, we deserve praise; if we do what we are convinced or suspect is wrong, unjust, unworthy of a man, we deserve blame and punishment. But an insane man may do the most unjust act, and yet feel invincibly convinced that it is just; he cannot then be held responsible for doing it, because the root of responsibility is then wanting.

I do not, however, maintain that one who is insane on any one point is thereby made irresponsible for all his actions. If he does what he thinks to be wrong, he acts against the dictates of his conscience, he deserves punishment from God; and if he violates a just law of the land, and it can be proved that his deed proceeded from a bad will, he may be punished by the civil courts as well, even though he is insane on other points. For instance, if a young man were to have a crazy notion that his father disliked him, that he is often in various ways unjust to him, and if, in consequence of this insane conviction, he were to attempt his father's life, he should be punished for the criminal act; because, even according to the way he views the matter, he could not be justified in killing his father for such a reason. It were different if he insanely imagined that his father was in the act of killing him, and that he could not escape death but by killing his father first; for then he could plead the right of self-defence against an unjust aggressor, as he foolishly imagines his father to be.

The conclusion then from all this explanation is that an insane man should not be held responsible for a deed which he insanely thinks to be right; but he is responsible for all his other acts.

In our next lecture we shall consider more fully the treatment of the insane by the civil and criminal tribunals.