INSANITY
IN ITS
MEDICO-LEGAL RELATIONS.


BY


A.'      OWPERTHWAIT, A. M., M. D.
J. M. STODDART & CO.
No. 723 CHESTNUT ST.,
1876.



Entered according to Act of Congress, in the year 1876, by
A. C. COWPERTHWAIT,
in the Office of the Librarian of Congress, at Washington.



PREFACE.
IN presenting these pages to the public, the author
does not flatter himself by thinking that he is bringing forward any strikingly new or original ideas in regard
to insanity; on the contrary, he has endeavored to incorporate, in as little space as possible, the ideas and observations of those who have already become eminent as alienist
physicians, with a somewhat extended experience of his
own, and thus to produce a work, which, while it may be
very brief, will contain those essential facts relating to the
pathology and diagnosis, and the legal relations of insanity,
which should be familiar to every physician, and the knowledge of which is of absolute necessity to him when called
upon to testify in courts of justice.
The remarkable prevalence of mental diseases in late
years, and the growing tendency thereto, especially in our
own country, together with the enormity of crimes which
are being constantly laid at its door, make it a matter of
paramount importance, that every physician should be
thoroughly posted in regard to insanity in all its relations,
legal as well as medical.
In all cases, the liberty of the individual suspected of
insanity, depends upon the diagnosis of the physician;
how important the trust, how great the responsibility therefore, when we take into consideration the impending misery
or happiness of all concerned. Yet this trust falls into comparative insignificance by the side of that which devolves
upon the physician, when his word is to decide the life or
death of the unfortunate criminal. How necessary, then, a
(v)



vi


Preface.


thorough knowledge of the whole of mental pathology,
and how greatly to be regretted, is the wide spread professional apathy and ignorance concerning it.
In the language of a recent writer: " Were the vast
array of incipient lunatics, who mingle unrecognized
among our large population, to be suddenly discovered,
the shock upon the community would be profound.
Nevertheless, it would be wholesome. If the world clearly
understood how much of the eccentricity and the moral
perversity manifested by individuals was to be ascribed to
a positive derangement of the material instrument of
thought, and how much to a purely capricious and depraved
will, its judgments, in courts of law and at the tribunal
of society, would be more just and charitable."
There is no question now before the public, involving
more broad and serious consequences than that of the
comparative sanity and moral responsibility of criminals
and wrong-doers. In every case of erring or singular
action, the inquiry into the motive should include a consideration of the relative soundness of the brain that
prompted it. Now that the fact is known that a slight
change in the flow of blood to the head, or a little impoverishment or impairment of the vital current, is able to produce at least a temporary disorder of the mind, it becomes
intelligent and humane men to inform themselves perfectly
as to the physical conditions under which evil deeds are
committed before a settled verdict is passed upon them.
This obligation might seem to impose too arduous a burden of research in order to reach equitable conclusions;
but it is quite as easy to elicit the truth regarding ancestry,
bodily health, and habits of thought and action, as it is to
secure the ordinary and superficial facts on which the
judgments of mankind are usually based.
If then, this little work may be the means of exciting
an interest in the profession upon this important subject,
and at the same time, exert its influence in begetting in law
and in society, a more humane and charitable feeling, not only






Insanity.-Introduction.


3


was one of faa to be determined by the jury on evidence.
Experts may testify to the conditions of mental disease as
they could not if such indications were matters of law."
Judge Doe further observes that legal tests of responsibility
have always been derived from medical authorities, who
profess to have founded their opinions on the observation
of fads. They are virtually the dida of medical men,
of experts-conflicting and liable to grow obsolete; and,
therefore, in passing judgment upon them, the courts adually trespass on the province of the expert. They change
with the progress of knowledge. Tests and definitions of
insanity once supposed to be corred and comprehensive,
have given place to others regarded as representing the
known fats of science. Whether they are corre& or incorre&, current or obsolete, is a question not for the
court, but for the expert to answer.
The same dotrine was repeated by Judge Doe in the
case of State vs. Pike, in which he observes that "the legal
profession, in profound ignorance of mental disease, assailed the superintendents of asylums, who knew all that
was known on the subjed, and to whom the world owes
an incalculable debt, as visionary theorists and sentimental
philosophers, attempting to overturn settled principles of
law; whereas, in fa&, the legal profession was invading the
province of medicine, and attempting to install old explodeo
medical theories in the place of faAs, established in the
progress of scientific knowledge."
In the same case, Chief Justice Perley instruted the
jury "that all symptoms and all tests of mental disease are
purely matters of fad to be determined by the jury."
In commenting upon these cases, Dr. Ray observes that
"against the course of these judges so strongly in harmony, as it is, with the established principles of law, it,
would be difficult to offer a satisfa6tory objedion. However necessary the present pradice may have been in former
times, when juries were ignorant of the little that was
known respeding insanity, and were obliged to rely on the



6


Pathology of Insanity.


may be given; but it should be borne in mind that it is the
whole evidence upon which an opinion is to be founded;
and, if that evidence is contradictory or deficient, the witness will best consult his own reputation, and promote the
ends of justice by candidly stating the fat.
CHAPTER II.
PATHOLOGY.
Insanity, unquestionably arises from a morbid ation of
the brain, and is only a symptom of disease of that organ.
For this reason it is not a proper object for definition as a
disease, nor is it possible to give the word insanity such a
meaning as will cover all possible morbid cerebral manifestations, and yet not include those cases of brain disease
which do not properly come under that head. According
to Hammond, insanity " is a manifestation of disease of
the brain, charaterized by a general or partial derangement
of one or more faculties of the mind, and, in which, while
consciousness is not abolished, mental freedom is prevented,
weakened or destroyed."
The brain is the seat of intelligence and volition, and
constitutes the grand centre of the supreme nervous system. Receiving, as it does, from the sensitive columns of the
spinal chord, and from the higher nerves of sense, the various impressions there created, it collects, associates and
assimilates these impressions, and forthwith excites a corresponding action of the mental system, which operates
upon every motor nervous ramification, and produces the
varied actions of life.  How these material impressions
upon the nerve fibres and cells can be converted into an
ad of consciousness, is utterly incomprehensible.
The ganglionic nerve cells of the brain are supposed to
be the centres of its funrtional adivity, as much as are the
ganglionic nerve cells of the motor system the centres of
its fundtional adtivity; and, if so, mind is simply a de



Pathology of Insanity.


7


veloped energy of nerve cell; but whatever be the real nature of the mind, it is most certainly dependent for its
every manifestation on the brain and nervous system.
It is interesting to note the intimate physiological relationship existing between the brain and other portions of the
nervous system, which indudively leads to the assumption
that the latter plays no small part in the creation of cerebral
manifestations, and that they hold within themselves, an important element of mental force.
In the lowest forms of animal life, no nervous system
exists, external impressions seemingly being received by
peripheral molecules, and transferred, by reason of the homogenity of its substance, from element to element, at last
resulting in visible movement.
In the second higher order of animals, the substance is
less homogenous, the molecular relations less intimate, and
a rudimentary nervous system appears, consisting of a single nerve cell conneting two fibres, which serve as conductors, and giving rise to the simplest form of reflex ation*
As we go still higher in animal life, the more heterogenous becomes the body, and the more diffuse and complex
the nervous system, until rudimentary organs of special
sense appear, and, with them, a corresponding increase of
ganglionic centres. Here the perception of external impressions is more varied and discriminating, partaking less
of reflex action and irritability, and more of that which is
designated as sensory perception and sensori-motor reaction.
As yet, however, no trace of cerebral hemispheres is
found, these first appearing in a rudimentary manner in the
fish, gradually enlarging as we ascend to the mammalia,
becoming nearly perfect in the higher mammalia, and fully
developed in man.
As soon as these hemispheres appear, external impressions are passed from the sensory centres to the brain centres, which, in accordance with their special nature, give
rise to ideas, forming another and higher type of sensibility
which is known as ideational perception.



10


Pathology of Insanity.


immaterial principle. Yet we find that in diseases of other
organs, pathological changes are also often absent, though
the presence of atual disease in these cases is not questioned. Because no pathological changes are found, is no
sign that nerve element does not subserve mental funtion.
We know comparatively nothing of the intimate constitution of nerve element, for the reason that it has so far baffled human investigation, yet, because we do not see the
changes, we should not conclude that they have no existence.
Serious disintegration of nerve element may occur from
various causes, without any discoverable pathological
changes. For instance, as a result of excessive or prolonged mental exertion, the brain may become, for a time,
entirely incapacitated for further fundtion, but without
any visible transformation of nerve substance, though an
increase of phosphates in the urine testifies to its disintegration. The lightning's stroke may produce instant death,
or leave its indelible mark in a shattered constitution and
disordered nervous system, yet, in neither case, does the
scalpel or microscope reveal any pathological change. So
might we produce many other fa&s to prove that serious
changes of nerve element do take place without any cognizable evidence, further than the accompanying modifications of nerve energy.
However, disseftions are abundantly proving the fat
that deviations from the healthy stru&ure of the brain, are
found in insane subjects, and when we remember the limited knowledge of brain anatomy possessed by pathologists
in the past, we may safely conclude with Dr. Ray, that
" the absence of these changes might be attributed, in not
a few instances, to the fault of the inquirer rather than to
the nature of the disease."
The instances in which morbid appearances in cases of
insanity are not found, " are," observes Maudsley, " becoming less frequent, as investigation improves; and those,who are best capable of judging, and best qualified by ac



Insanity.--Diagnosis.


33


the sober man becomes disappointed, the prudent man rash
and extravagant, the moral or religious man dissolute, the
modest woman shamefully indecent, there can be little
question of the presence of cerebral disease; yet, as previously remarked, search should be made for any predisposing causes that might operate in a natural way to
produce these changes. They are but a lack of control
over the affective and intelle&tual faculties, which are by
nature depraved, and which depravity is only restrained by
moral and religious principles. The question to decide is,
whether that lack of will-power is the subje&t of disease or
of natural causes.
It is necessary to conduct the personal examination of
the patient with the greatest ta& and discretion. It will not
do for the physician to at once attack the citadel of disease
by such leading questions as might not be inappropriate
or unusual in other diseases. A few years since, I was the
attending physician of a lady who exhibited marked symptoms of depression, and whose hereditary predisposition to
mental disease was unquestionable. In the course of her
treatment, an eminent physician of a neighboring city was
called in consultation. Almost the first inquiry he made
of the patient was: " Are you inclined to be melancholy?"
The patient and family were through with him from that
moment, and his superior abilities were ever after entirely
ignored. The patient, as well as the (amily, is usually
quite sensitive concerning any allusions to insanity; and, if
the former's suspicions are at once aroused, it will be
quite difficult to discover his real mental condition. The
physician may nearly always engage the attention and goodwill of the patient, if he will only employ that sympathy
and tad derived from good sense and a knowledge of
human nature, which is often appreciated as plainly by the
diseased mind as by others.
In entering the presence of the patient, the physician
should avoid a marked and obvious attention in his observations of the expression, demeanor, etc., but should as



34


Insanity.-Diagnosis.


sume a quiet indifference, though it must be done in a
natural manner, or the unfitting mask will at once excite
the patient's suspicions. While, to all appearances indifferently conversing on the most foreign topics, the observing physician may study the physiognomy and gestures of
the patient, and find in them much valuable aid; the eccentricity of dress, from mere disorder to total nudity, or
absurd peculiarities of arrangement in shape or color, so
often present, may also assist him in forming an opinion as
to the condition of mind; but here, as elsewhere, no established rules or symptoms can be given. Each individual case must be studied by itself, and nothing but
experience and a thorough comprehension of the peculiarities of diseased mental aCtion will prove unfaltering
aids. After the physician has, by ordinary conversation
on any subject, tested the attention, memory and judgment,
"the patient may be led to give an account of his own
powers of body and mind, with reference to health, to exercise, diet and study. Thousands of delusions are entertained by insane people upon these subjects. He may then
be led to converse respeCting his possessions, his means of
livelihood, and his hopes of advancement in rank or
property. Such conversation will open up the delusions
of pride, ambition an acquisitiveness. He may then be
led to converse of his near relatives and friends, and especially respeCting his birth and parentage, stress being laid
upon his belief whether his parents were his actual and real
parents. This inquiry will tend to open up any delusions
respeCting imaginary greatness, and any perverted emotions towards those who ought to be dear to him. The
subjeEt of religious opinion may then be introduced. The
religious devotions and exercises which he praCtices may
be inquired into, with the reasonable expeCtation of finding
insane delusions on a subject which touches the deepest
sentiments of the soul. If the patient is an educated man,
it will be right to converse with him upon politics and
science. If he can stand the test of a discriminating in



Insanity.- Criminal Responsibility of Insane.  49
ist, or if existing, it is not inuch manifest, and has not
to all external appearances influenced the act, then it is
held that he should be responsible. Even further does socalled justice go; for, if the person has a most frightful
delusion, but it cannot be known that the crime is a direct
result of that delusion, then he must be responsible. With
a delusion to prove in general a diseased mind, who can
say there are not other delusions reigning concealed, and
which have constituted the motive for the act? However,
the great trouble is, that delusions as a mark of insanity,
are greatly overestimated. On this point, Maudsley remarks, that " not half the insane acts of a person laboring
under general mania, are really the offspring of his delusions; they represent the overflow of morbid energy, are
often aimless and motiveless, so far as we can judge, the
mere convulsive expressions of disordered nerve centres.
Even the acts which are the offspring of delusion, are not.such as are the logical outcome of it, or such as are adapted
to the attainment of the delusive aim; they are the results
of insane reasonings from insane premises, or of impulses
which sping up in insane minds without being connected
with the existing delusions." As an example for criticism,
he supposes an individual to believe himself to be Jesus
Christ, being otherwise entirely rational, but who one day,
shoots somebody, and is put on trial for murder. The act
cannot be shown to be the direct result of delusion; nor
if it were, it would hardly be in accordance with the character of Jesus Christ, to do murder, and as the madman
must be consistent in his delusive character, therefore, he
is righteously convicted and executed.
In no civilized country in the world would such a person be executed as a murderer, though such a theory is
constantly held, and as a theory is always violated in
practice. We cannot delve within the insane mind and
follow its incoherent workings without first becoming insane ourselves; for in this way only could we understand
and appreciate its insane reasonings. " The delusion is



Treatment of the Insane.


78


should be hung in order to protect society, when society
has the power of protecting itself effectually by other
means.
Before closing this chapter it may not be inappropriate
to notice briefly the treatment of those insane persons who
have never become the perpetrators of criminal acts.
In no other direction is progress in the culture and practice of the humane virtues better exhibited than in the improved treatment of the insane. Until a very recent period,
this unfortunate class of persons were almost universally
neglected and shunned, and, to a great extent, abused and
cruelly treated. In some countries they were regarded
with reverence, as stricken by the direct hand of God; in
others, they were regarded as proper subjects for the torment of coarse, unfeeling jest, ridicule, and derision; and,
in others, they were imprisoned, as social pests, or even
executed as criminals. The religious houses gave a partial refuge to lunatics during the medieval ages; and, when
these were dissolved, hospitals, popularly called bedlams,
were established for their reception. The management in
these institutions was everywhere most deplorable, owing
to the ignorance and the cruelty of keepers and physicians.
Asylums, properly so-called, were not brought into being
before the beginning of the present century.  Even in
these improved infirmaries, the treatment of patients was
for some time marked by the old and time honored barbarity. The idea had so long been accepted, that, when
reason departs from its seat in the mind, it leaves the human being a mere animal, oftentimes more furious and
dangerous than the wild beast, it was hard to exchange it
for newer and more intelligent conceptions. Devices of a
diabolical nature were contrived, even after the dawn of our
enlightened century, to subdue what was considered to be
the evil demon raging within the breast of the insane. One
of these was to entice the sufferers to walk across a floor
that suddenly gave way and, plunged them into a cistern
of water, in which they were half-drowned and half-fright