Responsibility in mental disease

Front matter

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

i EX LIBRIS |

Preface

niitted homicide instead of, or as well as, theft, as he might easily have done, and that I had appeared at his trial and described the slight antecedent symptoms which enabled me in the first instance, and Dr. Browne afterwards, to diagnose fatal disease of the brain ; will any one believe that my evidence would have been received with less ridicule and incredulity than that with which Dr. Browne's evidence and my certificate were received at the trial for theft? The prisoner would assuredly have been convicted, and in all probability executed long before the progress of his fatal disease had proved the correctness of the medical diagnosis. The true remedy for the present unsatisfactory state of things, I venture to think, lies not, as my critic in the Pall Mall Gazette supposes, in the justification of a medical diagnosis to an audience which understands nothing of the disease which is described, or even of the terms in which alone it can perhaps be described, but in abolishing the ignorance and selfsufficiency which makes medical evidence unintelligible and unacceptable. There will be no difficulty in doing it if there be only the will to do it: let the judge appoint an experienced physician to give an independent report to the court, or let him have the aid of such a physician as an assessor, and there will soon be an end of the scandals of the present system, and the beginning of a better state of things.

Chapter I. Introductory

___ PAGE

Insane persona in asylums : now much they resemble and how much they differ from sane persons — Erroneous popular and legal notions — Feeling of repulsion towards insanity — Cruel treatment of the insane : from what causes it originated — Effects of the theological and the metaphysical spirit — Mind a function of brain, and disordered mind a result of disordered brain — Influence of bodily organs on mental function — Physiological method of inquiry indispensable ; inadequacy of psychological method — Development of nervous system by education, and its necessary limits — The tyranny of organization — Hereditary influence— Moral responsibility — The criminal nature — Hereditary crime— The production of criminals : their defective physical and mental organization, and proneness to disease — Border-land between insanity and crime — Causes, course, and varieties of intellectual and moral degeneracy to be studied by the inductive method. ..... 1-37

Chapter II. The Borderland

No distinct line of demarcation between sanity and insanity — Continuity in nature — The borderland — The insane temperament — Transformation of nervous diseases — Kinship between insanity and epilepsy, neuralgia, chorea, dipsomania — Functional and organic diseases of the brain — Hereditary predisposition : ita pathological evolution through generations — Originalities of

XXIV CONTENTS.

PAGE idea, feeling and impulse in connection with it — Insanity and the prophetic mania — The prophets of the Old Testament — The epileptic nature of Mahomet's visions and revelations— The madman and the reformer— Eccentricity and insanity — Deficiency or absence of moral sense a. congenital fault of mental organization— Crime and insanity — Moral sense : its acquisition in the course of evolution ; and its dependence upon organization— Physical conditions of moral degeneracy — Conclusions. ....... 38-G5

Chapter III. Different Forms Of Menta1 Derangement

Idiocy and imbecility —Kleptomania, pyromania, &c, often mark imbecility — Intellectual and Affective insanity — General and partial maDia — Monomania and melancholia — Dementia — General paralysis of the insane — Objections to the received system of classification according to certain prominent mental symptoms only — The lines on which it is proposed to lay down a better system — The diagnosis of insanity a strictly medical question — Morel's proposed classification — Skae's proposed classificatiou — The path of future medical inquiry — The physician's duty to declare the truth, however unpopular it may be. GG-S7

Chapter IV. Law And Insanity

Early legal notions of insanity— Lord Hale's dictum— Mr. Justice Tracey's wild beast theory of madness— The trial of Hadfield : Erskine's declaration that delusion was the true character of insanity — The trial of Bellingham : Chief Justice Mansfield's dictum that a knowledge of right and wrong generally was the proper criterion of responsibility— The trial of McNaughten : answers of the English judges to questions put

CONTENTS. XXV

FACE by tbe House of Lords — A knowledge of right and wrong in reference to the particular act at the time of committing it laid down as the true criterion of responsibility — One exception to this rule formulating the question to be left by the judge to the jury — Assumption by the judge of the function of the jury — Criticism of the answers of the English judges by American judges — Uncertainty of result in English trials where iusanity is alleged — The dicta of American judges : cases of Boardman v. Woodman, State v. Jones, and State v. Pike —Articles of tho French penal code and of the latest German penal code — Comment upon the right-and-wrong theory of responsibility. Formal legal views of testamentary capacity : cases of Cartwright v. Cartwriijht, Dew v. Clarke, and Waring v. Waring— Recent American decisions — Judgment of the Court of Queen's Bench in the case of Banks v. Goodfellow — Comparison of the law relating to testamentary capacity with the law relating to criminal responsibility ..... 8S-120

Chapter V. Partial Insanity

I. — Affective Insanity.

Insanity comprises several forms of mental derangement — Variations in the character of the symptoms of each form at different periods of its course — Early symptoms sometimes little marked, but of great significance : examples — Medical observation alone of the early stages of any value : misinterpretation of them by lawyers and others — Uselessness of the capital punishment of insaue persons as an example to others.

Affective insanity : 1. Impulsive insanity. Insane suicidal impulse or suicidal monomania : examples — Pathological nature of the insane impulse : an inability to control it may be accompanied by a consciousness of its morbid nature — Suicidal insanity strongly hereditary : example — Homicidal monomania : examples — Discussion of its nature — Perverted desires and deranged vi CONTENTS.

PAOE impulses common features in all forms of mental derangement — Symptoms of derangement before an outbreak of homicidal insanity— Latent tendencies may discover themselves for the first time on the occasion of a powerful exciting cause — Conditions precedent of an outbreak : a. the insane neurosis ; b. the epileptic neurosis — a. Insane neurosis : with some degree of imbecility — case of Burton : -without imbecility, but with manifestation of insane tendencies — case of Alton murderer — The homicidal impulse : was it irresistible or unresisted ? — b. Epileptic neurosis : the homicidal mania may precede, take the place of, or follow an epileptic fit — 2. Moral insanity : its characteristic features and its causation— Moral alienation often precedes intellectual derangement, and remains after this has passed away ; attacks of it may alternate with attacks of regular mania and melancholia— Folie circulaire — Moral alienation in connection with epilepsy— Congenital moral imbecility— Conclusion. .... 121-184

Chapter VI. Partial Insanity

II. — Partial Intellectual (or Ideational) Insanity.

Simple melancholic depression preceding intellectual derangement : homicidal or suicidal outbreak : case of Charles Lamb's sister — Melancholia with hypochondriacal hallucinations and delusions ; homicide — Delusions of suspicion or persecution, and homicidal mania: case of Dr. Pownall — Concealment of their delusions by insane persons — Bodily symptoms preceding an outbreak of homicidal mania : the characters of the attack — Dangerous character of the insanity that is accompanied by delusions of persecution — An insane person does murder out of revenge : is he a responsible agent ?— Futility of argument against » delusion : a limited delusion indicates deeper mental derangement : examples — Premeditation in planning and ingenuity in perpetrating homicide entirely consistent with insanity : ex-

CONTENTS. XXV11

PAOB ample — Danger of recurrence of homicidal mania : examples — Conduct of insane persons after a homicidal act — Homicidal insanity in which, first, the act is the direct offspring of the delusion ; and, secondly, in which it caunot be traced to its influence — Hoffbauer's metaphysical criterion of responsibility — The medical doctrine that partial insanity excludes the idea of criminality, whether or not the acts are the results of delusion : the reasons on which it is based — Discussion of the legal and medical views with regard to the working of an insane delusion in the mind : examples showing the impossibility of tracing its workings — Pathological meaning of the existence of an insane delusion, however limited — The right problem in homicidal insanity is to trace a connection, not between the delusion and the act, but between the disease and the act.. ...... 185-22G

Chapter VII. Epileptic Insanity

Mania following epilepsy : its furious character — Masked epilepsy — Mental disorder preceding the epileptic attack — Epileptiform neurosis manifesting itself in periodical attacks of mental derangement : examples — Description of the symptoms of epileptic insanity : of those that go before and foretell an attack ; of those that are exhibited in the milder and the more severe forms of the disease ; and of those that are met with after long- continued epilepsy — Peculiar states of epileptic consciousness — Epileptic visions — Transitory mania, of epileptic origin: examples— Features of epileptic homicide — Transitory mania, without history of epilepsy — Somnambulism — The persistence of dream-hallucinations after waking from sleep. 227-253

Chapter VIII. Senile Dementia

Symptoms of senile dementia in the order of their occurrence : loss of memory, impairment of perception, incoherent talk, in-

XXT111 CONTENTS.

PAGE

capacity of comprehension, complete mental decay — Comparison of its symptoms with those marking the natural decay of mind in old age— The mental character of old age — Failure of mind in febrile and other diseases — Loss of consciousness of personal identity. ..... 254-207

Chapter IX. The Prevention Of Insanity

Man's power over himself to prevent insanity — Outcomes of an insane temperament — The exercise of self-control in insanity — The gradual evolution of character — The development of will : its power over the thoughts and feelings — The propagation of insanity through generations — Unwise marriages — The tyranny of the passion of love— The degeneration and regeneration of families — The intensification of the neurotic type — Hereditary predisposition, intemperance, and mental anxieties as causes of insanity — Exposition of the evil effects of intemperance — The prevention of insanity by education — The aim of a liberal education — Self-culture as an aim of life— Inconsistencies of thought, feeling, and actions : the injury to character which they imply — The kind of mental activity involved in the conduct of business : how it fails to satisfy the requirements of true mental culture— Mistaken views of religious duties — The control of the emotions— Mental hard work not a cause of insanity — The full development of the mental faculties a protection against insanity — Undeveloped mentality— The study of the natural sciences as a means of intellectual and moral training — The reign of law in human evolution —The moral duties consequent on the intellectual recognition of it 268-308

EESPONSIBILITY IN MENTAL DISEASE.

Chapter I. Inteoductoey

Insane persons in asylums : how much they resemble and how much they differ from sane persons — Erroneous popular and legal notions — Feeling of repulsion towards insanity — Cruel treatment of the insane : from what causes it originated — Effects of the tlieological and the metaphysical spirit — Mind a function of brain, and disordered mind a result of disordered brain — Influence of bodily organs on mental functiou — Physiological method of inquiry indispensable ; inadequacy of psychological method — Development of Dervous system by education, and its necessary limits — The tyranny of organization — Hereditary influence — Moral responsibility — The criminal nature — Hereditary crime — The production of criminals : their defective physical and mental organization, and proneness to disease — Border-land between insanity and crime — Causes, course, and varieties of intellectual and moral degeneracy to be studied by the inductive method.

Notwithstanding the great change which has taken place in opinion and practice with regard to mental disease within the last century, there are still persons who, if invited to visit a lunatic asylum, would look on the proposal in much the same light as a proposal to visit the Zoological Gardens and inspect the wild beasts. They would certainly expect to see something entirely unlike what they were used to see in their daily experience, and would probably come away not a little disappointed with the result of the visit : like Mr. Burke, they might ask, at the end of it, where the insane persons were. It is related of that great philosopher, orator, and statesman that, after going through the wards of a large lunatic asylum, he turned to the gentleman who had accompanied him, and said that he had not seen one person whom he considered insane. Thereupon his conductor called one of the patients who had particularly interested Mr. Burke by his ingenious political theories, and touched the subject of his delusions, when he began immediately to talk of the porcupine quills which he imagined to grow from his skin after each meal, and became so incoherent that Mr. Burke was convinced that madmen were not all like the pictures which Hogarth painted of them.

For the most part, they are very unlike. Of the inmates of an asylum, some few might present noticeable peculiarities of appearance, demeanour, and conversation; more would strike tbe observer by their dull look and listless attitude, as if they had no interest in anything in the heavens above or in the earth beneath ; while others would not show, either by their looks or by what they said or did, that they were not as other men are. So much would the casual observer see. The skilled observer would see more, but even he would not find a new world and a new race of beings ; he would find man changed, indeed, but not transformed. He would meet, as Esquirol has remarked, with " the same ideas, the same errors, the same passions, the same misfortunes : it is the

ERRONEOUS POPULAR AND LEGAL NOTIONS. 3

same world ; but in such a house the traits are stronger, the colours more vivid, the shades more marked, the effects more startling, because man is then seen in all his nakedness, because he does not dissimulate bis thoughts, because he does not conceal his defects, because he lends not to his passions the charm which seduces, nor to his vices the appearances which deceive."

Were the observer, whether casual or skilled, to reside for some length of time in an asylum, and thus to make himself practically acquainted with the ways, thoughts, and feelings of its inmates, he would certainly discover how great a mistake it is to suppose, as is often done, that they are always so alienated from themselves and from their kind as not to be influenced by the same motives as sane persons in what they do or forbear to do. When an insane person is on his trial for some criminal offence, it is commonly taken for granted by the lawyers that if an ordinary motive for the act, such as anger, revenge, jealousy, or any other passion, can be discovered, there is no ground to allege insanity, or, at any rate, no ground to allege exemption from responsibility by reason of insanity. The ideal madman whom the law creates is supposed to act without motives, or from such motives as it enters not into the mind of a sane person to conceive ; and if some one, who is plainly mad to all the world, acts from an ordinary motive in the perpetration of an offence, he is presumed to have acted sanely and with full capacity of responsibility. No greater mistake could well be made. Much of the success of the modern humane treatment of insanity

B 2 rests upon the recognition of two principles : first, that the insane have like passions with those who are not insane, and are restrained from doing wrong, and constrained to do right, by the same motives which have the same effects in sane persons ; secondly, that these motives are only effective within limits, and that beyond these limits they become powerless, the hope of reward being of no avail, and the expectation or infliction of punishment actually provoking more unreason and violence. By the skilful combination of these principles in practice it has come to pass that asylums are now, for the most part, quiet and orderly institutions, instead of being, as in olden times, dens of disorder and violence, and that the curious sight-seer, who visits an asylum as he would visit a menagerie, sees nothing extraordinary, and comes away disappointed.

And yet, although in much so like, how different is the madman essentially ! Be the change in him what it may, it is plain that he has fallen from man's high estate, that he is no longer one with his kind, that he has lost the highest human attributes — those by which man is what he is among animals. Learned men may dispute concerning the nature and extent of the change ; but the wayfaring man, though a fool, cannot fail to perceive it. Nor does the change fail to influence him : deep in his heart there is generated an instinctive feeling of distrust, if not of actual repugnance ; he recoils in spite of himself from the distortion of humanity. Notwithstanding much benevolence of sentiment towards those who are afflicted with insanity, and much righteous indignation against those

CKUEL TREATMENT OF THE INSANE. 5

who ill-use them, it is still true that the public look upon the disease as a calamity of quite special kind, conceal it as a disgrace, and sometimes treat it as a crime. By the feeling evinced, so unlike that which any other disease elicits, one is reminded of the way in which the lower animals and some savages act when one of their number falls sick : they slacken not their speed to allow the sufferer to continue with them, but leave it by the wayside to perish alone ; so far from helpful sympathy, they evince actual antipathy and drive it from among them : it is the saddest sight, indeed, to see the way in which animals thus persecute sometimes the sick and helpless member of the herd.

Happily it results from the moral development of civilized man that he does not so act towards one who has fallen sick of an ordinary bodily disease; on the contrary, the affliction elicits his warm sympathy and active help. But it is uot in the same measure so when the sickness is a sickness of mind. There is a dim but deep instinct that this is not a disease which is quite like other diseases, that a man by it " from himself is ta'en away," alienated from himself and from his kind, and that he is something of a reproach to the nature of humanity ; the result being a vague feeling of antipathy like that which the lower animals display towards one of their kind that has fallen ill. At bottom this might seem to be curious evidence of the operation of the law of natural selection, whereby a diseased member that is unfitted for the natural functions of its kind is instinctively extruded from companionship. Just as the lower animals, and the savages who have to wander long distances, abandon or drive away the member that is incapacitated by bodily illness from holding its ground, and whose presence would be an encumbrance ; so, in like manner, civilized nations, until recently, thrust out of sight into vile receptacles, where no mention of them more was heard, those members of the community who, through loss of reason, were unable to hold their own in the struggle for existence, and whose presence was felt as an encumbrance, a reproach, and a danger.*

One of the saddest chapters in human history is that which describes the cruel manner in which the insane were treated in times past. Notwithstanding that it is happily a thing of the past, it will be instructive to inquire from what causes the barbarous usage sprang : for it was not common to all nations and all times; on the contrary, it had its birth in the ignorance and superstition of the dark ages of Christian Europe. Whatever may have been thought of madness among the peoples who preceded the ancient Greeks — and there is evidence that the Egyptians adopted a singularly enlightened and humane treatment — it is certain that the Greeks had comparatively sound theories of its nature as a disease to be cured by medical and moral means, and adopted principles of treatment in conformity with those theories. Their dramatic poets, it is true, present terrible pictures of madmen pursued by the anger of the gods ; but these

* In the four or five pages -which follow, I have repeated in nearly the same words what has been already published in an address on "Conscience and Organization," in the second edition of my work on " Body and Mind."

ANCIENT VIEWS OF INSANITY. 7

were poetical representations, which must not be taken as a measure of the best knowledge of the time. Then, as now, and indeed as ever in the history of mankind, the true thinkers were emancipated from the fables and superstitions of the vulgar : the just measure of Greek intellect must be sought in the psychology of Plato, in the science of Aristotle, and in the medical doctrines of Hippocrates.

This eminent physician and philosopher expressly repudiates the notion that one disease is of more divine origin than another. After saying that the Scythians ascribe the cause of certain disorders to God, he goes on to give his own opinion that these and all other disorders are neither more nor less of divine origin, and no one of them more divine or more human than another ; that each has its own physical nature, and that none is produced without or apart from its nature. In what he says of the psychical symptoms of various diseases of the body he evinces such enlarged views of the scope of medical observation and practice as are not often evinced at the present day ; and the few observations in his Avorks respecting the symptoms of delirium " evidence that clear and correct view of disease which has made this first observer a model to all succeeding times." He directs attention to such facts of observation as the physical insensibility of the insane, the appearance of mental diseases in the spring, the occurrence of disorder of the intellect after a continuance of fear and grief, the union of melancholy and epilepsy, the critical importance of koemorrhoidal discharges in mania, the difficulty of curing madness which commences after the age of forty, and the like. And as there was no superstition in these doctrines, so there was no barbarism in his treatment, which was medical, and consisted principally in evacuation by the use of hellebore. But moral treatment was not unknown among the Greeks; for Asclepiades, who seems to have been the real founder of a psychical mode of cure, made use of love, wine, music, employment, and special means to attract the attention and exercise the memory. He recommended that bodily restraint should be avoided as much as possible, and that none but the most dangerous should be confined by bonds. Without going further into particulars, enough has been said to show that the Greeks had acquired accurate notions of madness as a disease, which was to be cured by appropriate medical and moral treatment.

How came it to pass that these enlightened views ever fell into oblivion ? The question is really only a part of the larger question, how it came to pass that the high aesthetic culture and brilliant intellectual development of the Grecian era, which might have seemed possessions of mankind for ever, were lost in the darkness and barbarism of the middle ages. To trace the causes of this so sad decline would be far beyond my present purpose ; suffice the fact tbat philosophy, which had mounted so high, was for a time sunk so low beneath the waves of superstition and ignorance, that it might well have never been in existence. And when at last a revival of learning took place, things were little better ; empty scholastic subtleties

EFFECTS OF THE THEOLOGICAL SPIRIT. 9

and metaphysical mysticism engaged the whole attention of men, who rivalled one another in verbal disputations, without agreement in the meaning of the terms they used, and in blind worship of the authority of Aristotle, without real regard to the true method of his philosophy or to the facts with which it dealt. As if knowledge were nothing more than a process of ingenious excogitation, they made no attempt to observe the phenomena of Nature, and to search out the laws governing them, but laboriously " invoked their own spirits to utter oracles to them ; " wherefore philosophy was little more than a web of unmeaning terms and of empty metaphysical subtleties.

With this sort of intellectual activity was joined, as the result of the detestable spirit which inspired monastic teaching and monastic practice, a harsh religious asceticism, through which the body was looked down upon with contempt, as vile and despicable, the temple of Satan, the home of the fleshly lusts which war against the soul, and as needing to be vigilantly kept in subjection, to be crucified daily with its affections and lusts. It was the earthly prison-house of the spirit whose pure immortal longings were to get free from it. Such was the monstrous doctrine of the relation of mind and body. What place could a rational theory of insanity have in such an atmosphere of thought and feeling? The conception of it as a disease was impossible : it was ascribed to a supernatural operation, divine or diabolical, as the case might be — was a real possession of the individual by some extrinsic superior power* If the ravings of the * The most learned physicians only put the devil a step further back,

10 BESPONSIBUJTy IN MENTAL DISEASE

person took a religious turn, and his life was a fanaticaj practice of some extraordinary penance — if, like St. Macarius, he slept for months together in a marsh, exposing his naked body to the stings of venomous flies, — or, like St. Simeon Stylites, he spent the greater part of his life on a pillar sixty feet high, — or, like St. Anthony, the patriarch of monachism, he had never, in extreme old age, been guilty of washing his feet, — he was thought to have reached the ideal of human excellence, and was canonized as a saint ; more often his state was deemed to be a possession by the devil or other evil spirit, or the degrading effect of a soul enslaved by sin ; from some cause or other he was a just victim of divine displeasure, and had been cast down in consequence from his high human estate.

It was the natural result of such views of madness that men should treat him whom they believed to have a devil in him as they would have treated the devil could they have had the good fortune to lay hold of him. When he was not put to death as a heretic or a criminal, he was confined in a dungeon, where he lay chained on straw ; his food was thrown in, and the straw raked out through the bars ; sight-seers went to see him, as they went to see the wild beasts, for amusement; he was cowed by the whip, or other instrument of punishment, and was more neglected and worse treated than if he had been a wild beast. Many insane persons, too, were

acknowledging "such a preparation arid disposition of the body through distemper of humours, which giveth great advantage to the devil to work upon ; which distemper beiug cured by physical drugs and potions, the devil is driven away, and hath no more power over the same bodies."

EFFECTS OF THE METAPHYSICAL SPIRIT. 11

■without doubt executed as witches, or as persons who had, through witchcraft, entered into compact with Satan., It is a striking illustration, if we think of it, of the condition of thought at that time, and of the great change which has taken place since, that such expressions as the black art, witchcraft, diabolical possession, and the like, have fallen entirely out of use, and would be thought to convey no meaning if they were used now. They were fictitious causes invented to account for facts many of which undoubtedly lay within the domain of madness.

Now it is a fact, abundantly exemplified in human history, that a practice often lasts for a long time after the theory which inspired it has lost its hold on the belief of mankind. No wonder, then, that the cruel treatment of the insane survived the belief in diabolical possession, though it is justly a wonder that it should have lasted into this century. The explanation of the seeming anomaly is to be sought, I believe, in the purely metaphysical views of mind which prevailed long after inductive science had invaded and made conquests of other departments of nature. Theology and metaphysics, having common interests, were naturally drawn into close alliance, in order to keep entire possession of the domain of mind, and to withstand the progress of inductive inquiry. With the notions they cherished of the nature of mind, and of its relations to body, it was thought impossible, and would have been denounced as sacrilegious, to enter upon the study of it by the way of physical research. To have supposed that the innermost sanctuary of nature could be so entered through the humble portals of bodily functions, would have been re- . garded as an unwarrantable and unholy exaltation of the body, which was full of all uncleanness, corruptible, of the earth earthy, and a gross degradation of the mind, which was incorruptible, of the heaven heavenly, and joint partaker of divine immortality. Whosoever had dared to propound such a doctrine would assuredly have been put to death as a blasphemer and a heretic. And yet he ought to have been hailed as a benefactor. It is impossible to say of any false belief which mankind have had that it has been the most pernicious in its effects ; but we may truly say of the theological notion of the relations of mind and body that it has been surpassed by few false doctrines in the evil which it has worked.