the same side as the evident cranial injury, it would be proper to
trephine on the opposite side of the skull in search of fracture or
hemorrhage, the result of contre-coup.
(_e_) In chronic epilepsy after traumatism of the head the indication
for trephining is present, but it is seldom a specific indication
connected with the subject of localization. Lesions of any part of the
skull and dura may be a cause of epileptic attacks, irrespective of
motor centres.
(_f_) In cases of tumor in the motor centres, if there be not symptoms
of tumors in other parts of the brain (multiple tumors) or of
penetration of the tumor to the central parts of the brain, we believe
trephining not only justified, but demanded in the present state of
science.
Some of the contraindications to trephining may be thus stated:
(_a_) Whenever in apparently favorable cases there are signs of injury
to the base of the brain, such as paralysis of cranial nerves, {98}
neuro-retinitis, and Cheyne-Stokes respiration (although the last
symptom may occur from simple compression).
(_b_) When hemispasm or hemiplegia is accompanied by hemianæsthesia,
thus making it probable that the lesion is deeper and farther back.
It should be added, in conclusion, that these indications and
contraindications are formulated from the standpoint of the
neurologist.
{99}
MENTAL DISEASES.
BY CHARLES F. FOLSOM, M.D.
DEFINITIONS OF INSANITY.—The term insanity conveys quite different
meanings to the community, to lawyers, and to physicians. From the
three points of view its definition has been constantly widening for
the past century. A great part of the alleged recent increase in
insanity is due to the fact that its definition is applied to more
people. Our insane asylums are more quiet and orderly, not only
because of the more humane treatment of the inmates, but largely also
because quieter and less insane people are now sent there than
formerly. Doubtless the mistake is sometimes made of going so far, in
zeal for science and philanthropy, as to make the definition of
insanity too broad; and in a refined civilization the nice adjustment
of complicated social relations, or even a fastidious taste, requires
people to be sent to insane asylums who in simpler states of society
would be cared for at home.[1]
[Footnote 1: The physician in general practice is referred to
Clouston's _Clinical Lectures on Mental Diseases_, and to Part 1 of
Spitzka's _Manual of Insanity_. For those who wish to study insanity
thoroughly the literature is rich and its bibliography is readily
available. Of many parts of the subject only an outline, of course,
can be given within the limits of the present paper.]
The popular idea of insanity is of wild, incoherent, or crazy conduct.
If maniacal, the timid or frightened young girl who would not hurt a
fly, and the tottering, harmless old man if confused and partly
demented, are hurried off to the asylum with the use and show of force
suitable for a desperate criminal, while the victim of overwhelming
delusions, because he seems clear, logical, and collected, is
vigorously defended against the physician's imputation of insanity
until he commits an offence against the laws, when he is fortunate if
he is not treated as a criminal. It is often impossible for judges,
juries, counsel, and even medical experts, to wholly divest themselves
of the popular notions of insanity in cases appealing strongly to the
passion or prejudice of the day. Cases involving the question of
responsibility for crime are decided against science and the evidence
because of certain preconceived notions upon insanity which no amount
of skilled opinion can controvert. Jurors, and less often judges, make
up their minds what a sane man would do under given conditions, and of
what an insane man is capable, judging from the facts within their own
experience; and in forming their decisions it is the act itself, and
not the man, diseased or otherwise, in connection with the act, that
chiefly governs them. Often they are right, not seldom wrong. Strange,
apparently purposeless, illogical, inconsistent action is frequently
attributed to the author of it being insane on that subject, whereas
he may be {100} simply acting from strong impulse or emotion, and may
be by no means insane. On the other hand, because a man knows right
from wrong in the abstract, and can ordinarily behave well, the very
characteristic workings of his insane mind are often seized upon as
unquestionable proof of sanity, even when they admit of no other
explanation to the skilled physician than that of insanity. There is
no doubt of the fact that the whipping commonly used in the treatment
of the insane by the monks several centuries ago put an end to much
insane conduct; and in insane asylums now, in spite of the best
efforts of the medical staff to the contrary, a brutal, bullying
patient is sometimes struck by another patient or an attendant in
return for some unusually exasperating and cruel conduct, with the
result of making him behave well in the future. It is with reference
to this class of cases that the crowd oftenest errs in its definition
of insanity. Society claims a voice in the enforcement of the laws for
its own protection, assuming to know who could control themselves from
crime and who not, and naturally wishes the standard of responsibility
to be kept high. Of course its sympathies and prejudices largely
govern its voice in the matter.
With precisely the same degree of insanity and the same power to
control their actions two murderers may be sentenced, one to death for
an act where the motive and method were those of the criminal, and the
other to an insane asylum for killing a person under circumstances
which are not explainable by sane reasons. The Pocasset Adventist who
sacrificed his loved child, as he thought, by the Lord's command,
would probably have been hanged if he had committed a crime similar to
John Brown's, Wilkes Booth's, Orsini's, or Guiteau's. Sometimes the
accused gets the benefit of the doubt, and sometimes society,
according to the view of the merits of the case taken by the judge in
his charge or by the jury in their verdict.
To the lawyer insanity means only a condition of mind with reference
to certain conduct. An insane man is simply non compos mentis.
Insanity is irresponsibility. The whole question to the lawyer is with
regard to a certain act or series of acts. The lawyer's definition is
narrower than that of the physician. In wills and contracts the course
is usually clearer than when there is a question of serious crime, and
even an insane person in an asylum may be a party to a valid contract
or make a will that will hold in law. It is not necessary that a will
or contract be such as would be made by a just man or a reasonable
man, but simply that it fairly represent the wishes and character of
the man making it, uninfluenced by any insane delusion or prejudice
caused by mental impairment; that the will or contract in itself bear
evidence of a correct appreciation of the circumstances and conditions
of the case; and that the mind be able to act independently enough,
with a reasonable knowledge of the duties of the individual and the
just rights of others. An unsound mind, as defined by the physician,
would cover a large portion of the convicts in our workhouses and
prisons to-day if they could be critically examined, but the lawyers
and courts would not find many of them insane. A man is not insane in
law unless his act is traceable to, or its nature has been determined
by, mental disease affecting his free agency; in other words, unless
insanity caused his act either wholly or in great part.
{101} In the partly irresponsible condition of mind often produced by
grave hysteria, so-called nervous prostration, and the general mental
and moral demoralization often seen in seduced and abandoned women, or
after exhausting illness, or following apparent recovery from cerebral
hemorrhages or embolism, blows upon the head, sunstroke, chronic
alcoholism, syphilis, etc., there may be loss of self-control and a
distinct moral perversion or decided change of character without very
evident mental impairment; and the courts recognize a diminished
capacity, as the result of disease, to appreciate and follow what is
right and just and to avoid what is wrong or unjust, and yet not
complete irresponsibility. In this connection the fact should be borne
in mind that a very little mental disease can make bad people
criminals, and may not take others beyond the bounds of propriety. A
criminal may become insane and be still pretty much the same kind of a
criminal as before. Morality, too, is relative, and many criminals,
like children, know almost nothing of abstract truth, justice, or
virtue, because they have never been taught them; and there are many
cases where the perverse or criminal actions of people may be about
equally explainable on the theory of insanity or wickedness. The
criminal, a creature of his surroundings and associations, may often
not be discriminated from the man with mental disease. Indeed, it is
not difficult to take the philanthropic position that all criminals
are insane because they are not in sympathy with the moral conceptions
of their time, or, to use the fashionable expression of the day,
because they are not in harmony with their environment. Such a view of
crime, however, leads to only one of two conclusions—either that
insanity is no sufficient defence for wilful violation of the laws, or
that all criminals should be treated as persons of unsound mind.
The free agency of the individual is affected or modified in many
different ways by the different diseases of the mind, and the question
of responsibility will often be found to be one of the most perplexing
problems with which the physician has to deal. If well-marked forms of
insanity alone were to be investigated, the matter would be
comparatively a simple one; but such is far from always being the
case. The insane man often commits certain crimes precisely as an
ordinary sane criminal would do the same thing. Often the evidence is
contradictory, the testimony as to previous life and character
conflicting, and the disease of so obscure a stage or type that it is
almost impossible to form a clear opinion. The determination of a
man's degree of free agency is no simple affair which can be decided
in all cases by a few or a few dozen interviews. Not seldom the
mystery remains unsolved after the autopsy. Man's free will is not the
property of any substance which can be demonstrated by chemistry,
physiology, or microscopical research, but it is the result of the
combined action of a whole group of functional activities the very
relations of which to each other are as unknown as their method of
action. No stethoscope or ophthalmoscope can reveal its morbid action,
which can only be inferred indirectly from the operations of the mind.
The cases in which the physician is called upon to define insanity as
the term is used by the lawyers are (1) to secure limitation or
control of an individual's actions, usually by a guardianship; (2) to
control him absolutely in an asylum; (3) to estimate his culpability
or criminality, or {102} his capacity to make a will or contract or to
transact business. It is quite important, therefore, that the medical
man should understand that there may be, as regards some particular
person, a wide difference between medical insanity or mental disease
and legal insanity or irresponsibility. He does most wisely when he
confines his testimony to an explanation of the changes caused by
disease in the particular case, and to the effect of such changes upon
the mind, leaving to the judge's charge and the jury's verdict the
questions of guilt and responsibility.
Insanity may be of congenital origin or slowly developed from early
childhood, but usually it indicates a change caused by disease, so
that the person alleged to be insane must, as a rule, be compared with
himself at some previous time, and not with some ideal standard of
mental health which does not exist. Indeed, if we could measure nicely
no two of us could be fairly held to precisely the same degree of
accountability. The knowledge of right and wrong is not a fair
criterion, as many insane men possess that knowledge well enough in
the abstract. The ability to distinguish right from wrong in the
particular act is possessed by some insane persons whose will and
power of self-control have become so limited by disease that they
cannot avoid what they know to be crime. Delusion overpowering the
mind is sufficient evidence of irresponsibility, but all delusions are
by no means so powerful that they cannot be resisted, and many must be
classed as simply false beliefs or mistaken views which could be, and
should be, controlled. In case, therefore, of alleged delusions not
manifestly insane further evidence of insanity is required, and the
way in which a man believes or does anything may be more of an
indication as to the soundness or unsoundness of his mind than what he
believes or does. A crime committed under the influence of maniacal
delirium, acute delirious mania, epileptic furor, uncontrollable
impulse, alcoholic insanity, or hysterical mental disease will usually
explain itself, while a demented insane person is so characteristic an
object that his crime cannot well be mistaken for that of a
responsible agent.
The different conditions of mind grouped under the general terms moral
insanity, affective insanity, and impulsive insanity are still the
bugbear of jurists, and there is a wide difference of opinion as to
the degree of accountability for actions performed under the influence
of moral perversion with only slight intellectual impairment; but the
degree to which the individual deviates from the path of the law may
depend more upon his training and surroundings than upon his
disease—points which must always be considered in establishing a
definition of insanity in obscure cases. Of two persons whose
circumstances in life, in connection with a certain amount of disease,
have produced as nearly as possible identical morbid mental states, it
now and then happens that the necessary surroundings of the one steady
and support him, while the associations and conditions of life throw
the other still more off his balance. The one is able to sustain the
ordinary relations with the world, the other not.
The intelligent study of mental disease by medical men has resulted in
its being detected at so early a stage and in such a mild form that
its proper treatment might almost be called, when successful, the
prevention of insanity. Cerebro-mental disease, though it be only in
its incipient form, implies to the physician the necessity for medical
treatment; but it {103} is another question whether the disease is
sufficient in amount to impair the power of self-control and will so
as to determine irresponsibility. It is not the doctor's province to
punish for crime, but to treat for disease, and he often forgets that
fact. The various medical definitions of insanity in textbooks and on
the witness-stand do not clearly enough state how far the medical and
how far the forensic meaning of the word is implied. What seem to be
wide differences of opinion regarding responsibility for crime, as
given in the courts, are often due to different ways of stating the
question, and nothing more.
Boileau said that all men are insane, the only difference between them
being the varying degrees of skill with which they are able to conceal
the crack; and Montesquieu, that insane asylums are built in order
that the outside world may believe itself sane. In 1832, Haslam, one
of the first experts in mental disease in England at that time,
testified in court that he had never seen a sane man in his whole
life, adding, “I presume the Deity is of sound mind, and He alone.”
It is impossible to give a satisfactory definition of insanity, to
draw any hard and fast line on one side of which we should put all the
sane, and on the other all the insane. It is not possible to divide
insanity from sanity by a single criterion, such as the existence of
delusions, inasmuch as many sane people have very curious delusions;
for instance, Sir William Blackstone's belief in witchcraft, as stated
in his _Commentaries on the Laws of England_; Martin Luther's
assertion that he saw the devil and threw an inkstand at him at a time
when a belief in a personal devil was required by the canons of the
Church of England; Napoleon's faith in his star; the common belief of
the French generals that Joan of Arc's hallucinations were divine
messages. Insane delusions have been defined as false beliefs,
impossible from the nature of things or the circumstances of the case,
according to general belief. One can only judge of each case and each
person by the conditions attending them. A belief consistent with one
person's whole life and character might indicate such a change in
another as to be a mark of insanity.
Hallucinations—“psycho-sensorial disturbances characterized by
sensations perceived when the exercise of the sense has not been
determined by any external excitation”—are characteristic of many
conditions of disturbed health besides insanity; and the same is true
of illusions—erroneous interpretations of sensations actually
perceived. In both cases the existence of insanity is determined by
the fact whether or not the erroneous impressions are corrected by the
judgment. An important point is to consider most carefully every
unnatural, strange, or unexplained action, whether deliberate or from
impulse, particularly in the large class of eccentric, ill-balanced,
or weak-minded persons on the border-line between sanity and insanity.
There are people who at one time seem to belong to the sane and at
another to the insane class. Baillarger states that the essential
element of insanity is loss of free will. Ball of Paris describes an
insane man as one who, in consequence of a profound disturbance of the
intellectual faculties, has lost more or less completely his free will
(liberté morale), and has ceased thereby to be responsible to society
for his actions.
Bucknill describes insanity, in his Sugden prize essay, as “a
condition of the mind in which a false action of conception or
judgment, a {104} defective power of the will, or an uncontrollable
violence of the emotions and instincts has been separately or
conjointly produced by disease.” Maudsley's definition is, “Insanity
is, in fact, disorder of brain producing disorder of mind; or, to
define its nature in greater detail, it is a disorder of the supreme
nerve-centres of the brain—the special organs of mind—producing
derangement of thought, feeling, and action, together or separately,
of such degree or kind as to incapacitate the individual for the
relations of life.... Mind may be defined physiologically as a general
term denoting the sum-total of those functions of the brain which are
known as thought, feeling, and will. By disorder of the mind is meant
disorder of those functions.”
Bucknill considers insanity a disease of the brain affecting the
integrity of the mind. Maudsley calls it a disorder of the mind of
such a degree as to incapacitate one for the ordinary relations of
life, implying that there may be certain deviations from the condition
of sound mind which do not constitute insanity. Tuke's definition is
that “insanity consists in morbid conditions of the brain, the result
of defective formation or altered nutrition of its substance, induced
by local or general morbid processes, and characterized especially by
non-development, obliteration, impairment, or perversion of one or
more of its psychical functions.” Instead of itself being a disease,
insanity, properly speaking, is a symptom of diseases which under
varying manifestations probably affect different functions of the
brain—at least they affect the brain in different ways.
As Krafft-Ebing says, “It is a logical, self-evident proposition that
the organ whose function under normal conditions is to bring about all
mental processes must be the seat of changes when these functions are
disturbed;” and Schüle adds, “The study of disturbances of the mind
involves the changes of the normal mental functions produced by
disease.... Mental diseases are brain diseases, but they are more than
that.” The normal action of the mind is a strange combination of
reason and impulse, varying greatly in different persons, and in the
same person at different times and under varying influences. The
relations of the one to the other, and their influence on action,
often change, under varying conditions and circumstances, in sane
persons, but still more in the insane.
Lord Bramwell once said that insanity is strong but not conclusive
evidence of innocence; and Lord Blackburn has stated that the jury
must decide in each individual case whether the disease of the mind or
the criminal will was the cause of the crime. The position of Sir
James Stephen in his _History of the Criminal Law in England_ best
states the most recent views of irresponsibility—namely, that “no act
is a crime if the person who does it is, at the time when it is done,
prevented either by defective mental power or by any disease affecting
his mind from controlling his own conduct, unless the loss of the
power of control has been produced by his own default.” He says that a
man laboring under such a defect of reason that he does not know that
he is doing what is wrong may be defined as one deprived, by disease
affecting the mind, of the power of passing a rational judgment on the
moral character of the act which he meant to do. There are persons too
insane to make a valid will by virtue of a single delusion, whose
right to vote, under the law prohibiting the insane from voting, would
not be questioned. Another {105} might not be held responsible for
crime, and still make a contract involving the rights of others
besides himself that would hold in law.
Bucknill's recent medico-legal definition of insanity is,
incapacitating weakness or derangement of mind produced by disease;
meaning, in criminal cases, inability of abstaining from the criminal
act, which would be expressed by Lord Bramwell's test, Could he help
it? Bucknill suggests as an amendment to the law of England that no
act is a crime if the person who does it is at the time incapable of
not doing it by reason of idiocy or of disease affecting the mind.
Any definition of insanity would be incomplete without the statement
of Hughlings Jackson's view, that disease only produces negative
mental symptoms answering to dissolution, and that all elaborate
positive mental symptoms (illusions, hallucinations, delusions, and
extravagant conduct) are the outcome of activity of nervous elements
untouched by any pathological process; that they arise during activity
on the lower level of evolution remaining; that the insane man's
illusions, etc. are not caused by disease, but that they are the
outcome of activity of what is left of him (of what disease has
spared), of all there then is of him. His illusions, etc. are his
mind.