Chapter V: Preface (4)

Further details on this point belong more properly to the lecturer on Medical Law. We are now concerned with the principles underlying special legislation. The main principle regulating all compensation is that there shall be a sort of equality between the services rendered and the fee paid for them. Ignorant people sometimes find fault with the amount charged as a Doctor's fee. There may, of course, be abuses by excess; but men have no right to complain that a Doctor will ask as much for a brief visit as a common laborer can earn in a day. This need not seem unfair if it be remembered that the physician had to prepare, during many years of primary, intermediate, and professional studies, before he could acquire the knowledge necessary to write a brief prescription. Besides, it may be that his few minutes' visit is the only one that day; and yet he has a right to live in decent comfort on his profession together with those who depend on him for support.

We must, however, remember, on the other hand, that excessive fees are nothing else than theft; for theft consists in getting possession of another's property without just title. The following rules of Dr. Ewell are sensible and fair:

"The number of visits required must depend upon the circumstances of each particular case, and the physician is regarded by the law as the best and proper judge of the necessity of frequent visits; and, in the absence of proof to the contrary, it will be presumed that all professional visits made were deemed necessary and were properly made.

"There must not be too many consultations. The physician called in for consultation or to perform an operation may recover his fees from the patient, notwithstanding that the attending physician summoned him for his own benefit, and had arranged with the patient that he himself would pay." (This, of course, does not mean that the practitioner has a right thus to shift the burden of pay from his own shoulders.) "Where a medical man has attended as a friend, he cannot charge for his visit. Where a tariff of fees has been prepared and agreed to by the physicians of any locality, they are bound by it legally as far as the public are concerned (that is to say, they cannot charge more than the tariff rates), and morally as far as they themselves are concerned" (p. 5).

In these rules Dr. Ewell regards chiefly what conduct the courts of justice will sustain. It is evident that the Doctor is never entitled to run up his bill without any benefit to his patient; where there is no service rendered at all, there can be no claim to compensation. Still it is not necessary that actual benefit has resulted to the patient; it suffices for the claim to the fee that measures have been taken with a view to such benefit. Even when no physical advantage can reasonably be hoped for from the visit, the consolation it affords the patient and his friends may render those who are to bear the expense fully willing that it should be often repeated and, of course, charged on the bill. Provided care be taken that they understand the situation, no injustice is done them. "_Scienti et consentienti non fit injuria_" is a good moral maxim.

II. We have said that the rights conferred on the physician by the state are conditioned on his performing certain duties. He owes the same duties to his patients in virtue of the contract, explicit or implicit, that he makes with them by taking the case in hand. Under ordinary circumstances, neither the state nor the patients can oblige him to exercise his profession at all; but, if once he has taken a case in hand, he can be justly held not to abandon it till he has given his patient a fair opportunity of providing another attendant; even the fear of contagion cannot release him from that serious obligation.

The duties arising from the physician's twofold contract, with the state and with his patients, are chiefly as follows:

1. He must acquire and maintain sufficient knowledge of his profession for all such cases as are likely to come in his way. No Doctor has the right to attempt the management of a case of which he has not at least ordinary knowledge. In matters of special difficulty, he is obliged to use special prudence or ask for special consultation. The courts justly hold him responsible for any serious injury resulting from gross ignorance; in such cases they will condemn him for malpractice. I would here remark that, in an age in which the science of medicine is making such rapid progress, every Doctor is in duty bound to keep up with the improvements made in general practice, and in his own specialty if he has one.

2. A second duty is that of proper diligence in treating every single case. Many a patient suffers injury to health or even loses his life in consequence of a Doctor's neglect. Gross negligence is an offence that makes him punishable by the court, if it results in serious injury. But even if such injury cannot be juridically proved, or has been accidentally averted, the moral wrong remains and is to be settled with the all-seeing Judge. Still, in ordinary ailments, no one is obliged to take more than ordinary trouble.

3. A third duty of the physician is to use only safe means in medical and surgical practice. He has no right to expose his patient to needless danger. What is to be thought of the use of such remedies as will either kill or cure? They cannot be used as long as safer remedies are available and capable of effecting a cure; for neither Doctor nor patient has a right to expose a human life to unnecessary risk. But when no safer remedies are going to effect a cure, then prudence itself dictates the employment of the only means to success. In such a case, however, the patient, or his parents or guardian, should, as a rule, be informed of the impending danger, so that they may give or refuse their consent if they please. For, next to God, the right to that life belongs to them rather than to the physician. The same duty of consulting their wishes exists when not life but the possible loss of a limb is at stake, or the bearing of uncommon sufferings. Moralists teach that a man is not obliged in conscience to submit to an extraordinarily painful or revolting operation even to save his life. Certainly, when the natural law leaves him at liberty, the physician cannot compel him to submit to his dictation; all he can do is to obtain his consent by moral persuasion.

4. As a consequence from the Doctor's duty to use only safe means it follows that he cannot experiment on his patients by the use of treatment of which he does not know the full power for good or evil. Nor is he excused from responsibility in this matter by the fact that the experiment thus made on one patient may be very useful to many others. His contract is with the one now under treatment, who is not willing, as a rule to be experimented upon for the benefit of others. And even if the patient should be willing, the Doctor cannot lawfully expose him to grievous danger unless it be the only hope of preserving his life. This follows from the principle explained before, that human life belongs chiefly to God and not to man exclusively.

5. There are various kinds of medical treatment to which we can scarcely have recourse without exposing ourselves to serious evil consequences. Such is the use of cocaine, morphine, and even in special cases of alcohol. The drugs in themselves are useful, but they often lead to evil results. Now in the use of all such drugs as are apt to be beneficial in one way and injurious in another, we must ever be guided by the rules formerly explained concerning evil indirectly willed, or rather permitted to result, while good results are directly willed or intended. If the Doctor is satisfied that a dose of morphine or an application of cocaine will do more good than harm, he can, of course, prescribe or apply it. Still in such matters he must remember that the good effect is but temporary, while its pernicious consequences, especially when habits are thus contracted, are likely to be permanent and cumulative. Besides, the good results affect the body only, the evil often affect body and soul. Many a wreck in health and morals has been caused by imprudent recourse to dangerous treatment, where a little more patience and wisdom would have been equally efficient in curing the bodily ailment, without any deleterious consequences. If once a patient becomes a slave to the morphine or cocaine habit, the only cure is to cut off all the supply of the drug either at once or, at any rate, by daily diminution. To leave him free control of the poison is to co-operate in his self-destruction.

6. The sixth duty of a Doctor is of a different kind. There exists a tacit or implicit contract between him and his patients that he shall keep their secrets of which he becomes possessed in his professional capacity. It is always wrong wantonly to betray the secrets of others; but the Doctor is bound by a special duty to keep his professional secrets; and it is doubly wrong and disgraceful in him to make them known. For instance, if he has treated a case of sickness brought on by sinful excesses of any kind, he is forbidden by the natural law to talk about it to such as have no special right to know the facts. Parents and guardians are usually entitled to be informed of their children's and their wards' wrong-doings, that they may take proper measures to prevent further evil. Besides, the Doctor is properly in their service; he is paid by them, and, therefore, his contract is with them rather than with the children. He can, therefore, prudently inform them of what is wrong, but he cannot inform others.

It is a debated question in Medical Jurisprudence whether the Doctor's professional knowledge of criminal acts should be privileged before the courts, so that he should not be forced to testify to a crime that he has learned from his patients while acting as their medical adviser. Dr. Ewell speaks thus on the subject (p. 2): "The medical witness should remember that, by the common law, a medical man has no privilege to avoid giving in evidence any statement made to him by a patient; but when called upon to do so in a court of justice, he is bound to disclose every communication, however private and confidential, which has been made to him by a patient while attending him in a professional capacity. By statute, however, in some of the United States, communications made by a patient to a physician when necessary to the treatment of a case are privileged; and the physician is either expressly forbidden or not obliged to reveal them. Such statutes exist in Arkansas, California, Indiana, Iowa, Ohio, Michigan, Minnesota, Missouri, Montana, New York, and Wisconsin. The seal upon the physician's lips is not even taken away by the patient's death. Such communications, however, must be of a lawful character and not against morality or public policy; hence, a consultation as to the means of procuring an abortion on another is not privileged, nor would be any similar conference held for the purpose of devising a crime or evading its consequences.

"A report of a medical official of an insurance company on the health of a party proposing to insure his life is not privileged from production; nor is the report of a surgeon of a railroad company as to the injuries sustained by a passenger in an accident, unless such report has been obtained with a view to impending litigation."

The practical rule for a Doctor's conscience on the subject of secrecy is, that he must keep his professional secrets with great fidelity, and not reveal them except in as far as he is compelled to do so by a court of justice acting within its legal power or competency. If so compelled, he can safely speak out; for his duty to his patient is understood to be dependent on his obedience to lawful authority.

As to the question of Jurisprudence whether the courts _ought_ to treat the physician's official secrets as privileged, in the same way as they do a lawyer's secrets, this will depend on the further question whether the same reasons militate for the one as for the other. The lawyer's privilege is due to the anxiety of the state not to condemn an innocent man nor a guilty man beyond his deserts. To avert such evil, the accused party needs the assistance of a legal adviser who can guide him safely through the mazes and technicalities of the law, and, even should he be guilty, who can protect him against exaggerated charges and ward off unmerited degrees of punishment. Now, this can scarcely be accomplished unless the attorney for the defence learn from his client the entire truth of the facts. But the client could not safely give such information to his lawyer if the latter's professional secrets were not held sacred by the court of justice.

Can the same reasons or equivalent ones be urged in behalf of the physician? I do not see that they can. And I notice besides that, if he be excused from testifying against his patients, all their servants and attendants would seem to be entitled to the same privilege. Many persons, I think, labor here under a confusion of ideas; a Doctor is as sacredly bound to keep his patients' secrets as a lawyer is in regard to his clients, but it does not follow that the law cannot grant a privilege to the one and refuse the same to the other, for reasons which require it in the case of the lawyer and not in that of the Doctor.

III. Besides the rights and duties which arise for the physician from his contracts with the state and with his patients, there are other claims on his conscience, which proceed from his character as a man, a Christian, and a gentleman.

1. _As a man_, he is a member of the human family, not a stranger dwelling amid an alien race, but a brother among brothers. He cannot say, as did the first murderer, Cain, "Am I my brother's keeper?" But rather he must carry out the behest of the great Father of the human family: "God has given to each one care of his neighbor."

The maxim of Freemasons is that every member of that secret society must come to the assistance of every brother-mason in distress. But the law of nature and of nature's God is wider and nobler; it requires every man to assist every fellow-man in grievous need. The rich glutton at whose door lay Lazarus dying of want was bound, not by any human but by the higher law, to assist him; and it was for ignoring this duty that the soul was buried in hell, as the gentlest of teachers expresses it.

(_a_) As physicians, as men, you will have duties to the poor, who cannot pay you for your services; they are your fellow-men. Their bill will be paid in due time. He is their security who has said: "Whatsoever you have done to the least of these, you have done it unto Me." He may pay you in temporal blessings, or in still higher favors, if you do it for His sake; but pay He will, and that most liberally: "I will repay," says the Lord. The rule of charity for physicians is that they should willingly render to the poor for the love of God those professional services which they are wont to render to the rich for pecuniary compensation. While thus treating a poor patient they should be as careful and diligent as they would be for temporal reward; what is done for God should not be done in a slovenly fashion.

(_b_) In this connection of regard for the poor, allow me also to call your attention, gentlemen, to a point which students of medicine are apt to forget at times, and yet which both God and the world require you ever to bear in mind: it is the respect which every man owes to the mortal remains of a departed brother. I do not know that a people has ever been found, even among barbarians, who did not honor the bodies of their dead. For the good of humanity, dead bodies may at times be subjected to the dissecting-knife, but never to wanton indignities. Reason tells you to do by others as you wish to be done by, and Revelation adds its teaching about a future resurrection and glorification of that body of which the Apostle says that "it is sown in dishonor, but it shall rise in glory." Be men of science, but be not human ghouls. There is such a thing as retribution. But lately a former millionaire died in a poorhouse and left his body as a cadaver for medical students. We cannot afford to ignore the mysterious ways of Divine Justice. Ever handle human remains in a humane manner; and as soon as they have answered the purpose of science, see that they be decently interred, if possible.

2. There are other duties that you owe not as men but _as Christians_. All of us enjoy the blessings of Christian civilization, even those who are not Christians themselves. We are dealt with by others on Christian principles, and we ought to treat others in the same spirit. What duties does this impose?

(_a_) When your patients are in real danger of death, let them have a good chance to prepare properly for their all-important passage into eternity. Give them fair warning of their situation. Doctors and relations are often afraid of alarming the patients and thus injuring their health. But those who attend Catholic patients at least soon find out by experience that the graces and consolations of the Last Sacraments usually bring a peace of mind that benefits even the bodily health. In any case, the interests of the future life are too important to be ignored.

(_b_) For the same reason, the physician should not prescribe such doses of morphine or other anæsthetics as will render the patient unconscious at a time when he ought to be preparing to meet his Judge. This would be not kindness but cruelty. A little suffering more in this life may save much suffering in the next. If a Catholic priest, on being called to a patient's bedside, finds that the family's physician has been so inconsiderate, he cannot help protesting against employing such a man in Catholic families.

(_c_) If you attend a woman in childbirth, you may be asked by a Christian mother not to let her child die without Baptism. The vast majority of Christians believe that this sacrament is necessary to obtain supernatural happiness. The ceremony is easily performed: no harm can come of it, but immeasurable good for eternity. It should properly be performed by the clergy. But if this cannot be done, any man, woman, or child, even one not a Christian himself, can administer the sacrament. Every Doctor in a Christian land should understand how to do it, and do it with unerring accuracy. It were a disgrace for him to be ignorant of what even an ordinary child is expected to know. The ceremony is so simple; and yet, being an institution of Christ, no man can modify it to suit his notions; if what is done is not just what Christ appointed to be done, it will be of no avail. Notice, therefore, carefully every detail. You will take a little water, say a cupful, real water--cold or lukewarm, that matters not--you will slowly pour it on the head of the child, and, _while you do so_, you will say, "I baptize thee in the name of the Father, and of the Son, and of the Holy Ghost." That is all. Notice, you must say the words while the water is being poured on the child. For "I baptize" means "I wash"; pour, therefore, or wash while you say, "I wash." Should you hereafter wish to refresh your memories on this matter, you can do so by consulting the "Century Dictionary," which explains Baptism, and in particular Catholic Baptism, as "consisting essentially in the application of water to the person baptized by one having the intention of conferring the sacrament, and who pronounces at the same time the words, 'I baptize thee in the name of the Father, and of the Son, and of the Holy Ghost.'" If a cup of water given to the thirsty brings a blessing, how much more the giving of the water of salvation! Should it happen that the child is in danger of dying before delivery, it should be baptized in the womb provided it be at all possible to cause the water to reach or wash its body, projected upon it by any instrument whatever; but the water should flow over the body, not merely over the cyst enclosing it, for the cyst is no part of the child. Even if but an arm or other minor portion of the body is washed, the baptism is probably valid. If any doubt about the valid administration is left, the infant after delivery should be carefully baptized _under condition_, as it is called; that is, with the condition added that, if the former ceremony was validly conferred, there is no intention of giving a second baptism. For that would not be right; since the sacrament cannot be validly received more than once; it is a sacred initiation, but it were mockery to initiate one that is already initiated.

Should a physician be present when a pregnant woman has recently expired, and the child may still be living in the womb, it will be an easy and important task to perform the Cesarean section as soon as possible, and baptize the little one before it dies. In all this there is no money, but what is far more precious, the securing of eternal happiness. I add with great pleasure that many physicians are wont to comply with all these instructions most carefully, and even to instruct midwives and nurses in the best manner of rendering such services.

3. Lastly, we must consider the duties which a Doctor owes to others and to himself _as a gentleman_. It may not be easy to define what is meant by "a gentleman," and yet to some extent we all know it; we recognize a gentleman when we meet one, we pay him sincere homage in our hearts. We readily allow him to influence us and to guide us. We esteem him instinctively as a superior being, as we distinguish a precious stone from a common pebble; so we value a gentleman for precious qualities exhibited in the beauty of his conduct. His conduct ever exhibits two characteristic marks: a proper degree of dignity or respect for self, and a proper degree of politeness or respect for others. Self-respect will not allow him to do anything which is considered vulgar, unmannerly, gross, rude, or selfish; he will avoid the two extremes, of self-neglect on the one hand and self-display on the other. His respect for others will make him treat all around him so as to make them feel comfortable in his presence; he will avoid whatever gives pain or causes embarrassment to even the lowest member of society.

Gentlemanliness has much to do with every one's success in life, and in particular with a Doctor's success. It is especially when sick that we are sensitive to everything displeasing in the conduct of others. It is not then the bold thinker or the extensive reader that is the acceptable visitor to the sick-room; but the gentlemanly consoler who always says the right thing at the right time, whose very eye expresses and whose countenance reflects the thought and sentiment most appropriate on the occasion.

There are most able physicians who are not gentlemen, and there are in the medical profession gentlemen who are rather poor physicians; but as a rule, I believe, the gentleman will thrive where the genius will starve. It is more or less the same in other professions. I know learned lawyers to-day who are far from prosperous, while men ten times their inferiors in learning are getting rich. I remember a most skilful physician, now no more on earth, who was a very genius in the science of medicine; but he was so filthy in his habits, he would so unceremoniously chew tobacco at all times, that many dreaded his visits, and would sooner have a man of less ability but gentler manners as their family physician.

Gentlemen, habits good and bad cannot be put on and off like a dress-coat; they are lasting qualities, the growth of years, the result of constant practice and self-denial or self-neglect. And, as I wish you success in life, allow me to conclude this lecture by recommending to you the assiduous cultivation of gentlemanly habits. Cultivate them now, while you are preparing for future labors. You wrong yourselves, and you insult your companions and your professors, when you neglect in their presence the conventionalities of polite society.

Uniting the external decorum of a gentleman with a thorough knowledge of your profession, and with what is still more important, the virtues of a conscientious man and a sincere Christian; ever true to the sound principles of morality which I have endeavored to explain and to inculcate in these lectures: you will be an honor to yourselves, an ornament to your noble profession, the glory and joy of your Alma Mater, a blessing to the community in which Providence will cast your lot as the dispensers of health and happiness and length of days to your fellow-men.

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.