Chapter 9

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.