WM M448r 1899 NATIONAL LIBRARY OF MEDICINE ___i NLM052148594 RESPONSIBILITY IN MENTAL DISEASE BY HENRY MAUDSLEY, M. D. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ; PROFESSOR OF MEDICAL JURISPRUDENCE IN UNIVERSITY COLLEGE, LONDON, ETC. AUTHOR OF BODY AND MIND, PHYSIOLOGY AND PATHOLOGY OF THE NERVOUS SYSTEM NEW YORK D. APPLETON AND COMPANY 1899 ,vi M 4 ? n. Authorized Edition. CONTENTS. CHAPTER I. INTRODUCTORY. PAGE Insane persons in asylums: how much they resemble and how much they differ f rom,the sane persons—Erroneous popular and legal notions—Feeling of repulsion to- wards 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; in- adequacy of psychological method—Development of nervous system by education, and its necessary limits —The tyranny of organization—Hereditary influence —Moral responsibility—The criminal nature—Heredi- tary crime—The production of criminals : their defec- tive physical and mental organization, and proneness to disease—Borderland between insanity and crime— Causes, course, and varieties of intellectual and moral degeneracy to be studied by the inductive method . 1-40 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, v i RESPONSIBILITY IN MENTAL DISEASE. chorea, dipsomania—Functional and organic diseases of the brain—Hereditary predisposition: its patho- logical evolution through generations—Originalities of idea, feeling and impulse in connection with it—In- sanity and the prophetic mania—The prophets of the Old Testament—The epileptic nature of Mahomet's visions and revelations—The madman and the re- former—Eccentricity and insanity—Deficiency or ab- sence of moral sense a congenital fault of mental organization—Crime and insanity—Moral sense : its acquisition in the course of evolution; and its depend- ence upon organization—Physical conditions of moral degeneracy—Conclusions......41-70 CHAPTER III. DIFFERENT FORMS OF MENTAL DERANGEMENT. Idiocy and imbecility—Kleptomania, pyromania, &c, often mark imbecility—Intellectual and affective insanity— General and partial mania—Monomania and melan- cholia—Dementia—General paralysis of the insane— Objection to the received system of classification ac- cording 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 pro- posed classification—The path of future medical in- quiry—The physician's duty to declare the truth, how- ever unpopular it may be......71-93 CHAPTER IV. LAW AND INSANITY. 1. 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 delu- sion was the true character of insanity—The trial of CONTENTS. vii 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 by the House of Lords—a knowledge of right and wrong in reference to the particular act at the time of commit- ting 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 insanity is alleged—The dicta of American judges : cases of Boardman v. Woodman, State v. Jones, and State v. Pike—Articles of the French penal code and of the latest German penal code—Comment upon the right- and wrong theory of responsibility. 2. Former legal views of testamentary capacity: cases of Cartwright v. Cartwright, 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 testa- mentary capacity with the law relating to criminal re- sponsibility ........ 94-129 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 symp- toms sometimes little marked, but of great signifi- cance : examples—Medical observation alone of the early stages of any value: misinterpretation of them by lawyers and others—Uselessness of the capital pun- ishment of insane persons as an example to others. iii RESPONSIBILITY IN MENTAL DISEASE. Affective insanity: 1. Impulsive insanity. Insane suicidal impulse or suicidal monomania : examples—Patho- logical nature of the insane impulse: an inability to control it may be accompanied by a consciousness of its morbid nature—suicidal insanity strongly heredi- tary : example—Homicidal monomania : examples— Discussion of its nature—Perverted desires and de- ranged impulses common features in all forms of men- tal 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 pre- cedent of an outbreak: a. the insane neurosis; b. the epileptic neurosis—a. Insane neurosis: with some de- gree of imbecility—case of Burton: without imbecility, but with manifestation of insane tendencies—case of Alton murderer—The homicidal impulse : was it irre- sistible or unresisted?—b. Epileptic neurosis: the homicidal mania may precede, take the place of. or follow an epileptic fit—2. Moral insanity: its charac- teristic 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 epi- lepsy—Congenital moral imbecility—Conclusion . 130-198 CHAPTER VI. PARTIAL INSANITY. II.—Partial Intellectual {or Ideational) Insanity. Simple melancholic depression preceding intellectual de- rangement : homicidal or suicidal outbreak: case of Charles Lamb's sister—Melancholia with hypochon- driacal hallucinations and delusions; homicide—Delu- sions of suspicion or persecution, and homicidal mania : case of Dr. Pownall—Concealment of their CONTENTS. ix delusions by insane persons—Bodily symptoms preced- ing 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 a de lusion : a limited delusion indicates deeper mental derangement: examples—Premeditation in planning and ingenuity in perpetrating homicide entirely con- sistent with insanity: example—Danger of recurrence of homicidal mania: examples—Conduct of insane per- sons after a homicidal act—Homicidal insanity in which, first, the act is the direct offspring of the de- lusion ; and, secondly, in which it cannot 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 impossi- bility 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 . . . 199-243 CHAPTER VII. EPILEPTIC INSANITY. Mania following epilepsy: its furious character—Masked epilepsy—Mental disorder preceding the epileptic at- tack—Epileptiform neurosis manifesting itself in peri- odical 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 RESPONSIBILITY IN MENTAL DISEASE. forms of the disease; and of those that are met with after long-continued epilepsy—Peculiar states of epi- leptic 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 . 244-272 CHAPTER VIII. SENILE DEMENTIA. Symptoms of senile dementia in the order of their occur- rence : loss of memory, impairment of perception, in- coherent talk, incapacity 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 feb- rile and other diseases—Loss of consciousness of per- sonal identity—Aphasia.....273-287 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 gener- ations—Unwise marriages—The tyranny of the pas- sion 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 in- sanity by education—The aim of a liberal education— Self-culture as an aim in life—Inconsistencies of thought, feeling, and actions: the injury to charac- CONTENTS. xi ter which they imply—The kind of mental activity in- volved in the conduct of business : how it fails to satisfy the requirements of true mental culture—Mis- taken 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 pro- tection against insanity—Undeveloped mentality— The study of the natural sciences as a means of intel- lectual and moral training—The reign of law in human evolution—Tne moral duties consequent on the intel- lectual recognition of it . . . . • 288-331 RESPONSIBILITY IN MENTAL DISEASE. CHAPTEE I. INTRODUCTORY. Insane persons in asylums: how much they resemble and how much they differ from the sane persons—Erroneous popular and legal notions—Feeling of repulsion towards insanity— Cruel treatment of the insane : from what causes it origi- nated—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 indis- pensable ; inadequacy of psychological method—Develop- ment 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 physi- cal 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 asy- lum, would look on the proposal in much the 1 2 RESPONSIBILITY IN MENTAL DISEASE. 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 disap- pointed 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 philoso- pher, 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 in- sane. 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 Ho- garth painted of them. For the most part, they are very unlike. Of the inmates of an asylum, some few might present no- ticeable peculiarities of appearance, demeanour, and conversation; more would strike the 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 INTRODUCTORY. 3 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 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, be- cause he does not dissimulate his 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 dis- covered, there is no ground to allege insanity, or, at any rate, no ground to allege exemption from re- sponsibility by reason of insanity. The ideal mad- man whom the law creates is supposed to act with- out motives, or from such motives as it enters not RESPONSIBILITY IN MENTAL DISEASE. 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 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 expecta- tion or infliction of punishment actually provoking more unreason and violence. By the skilful com- bination 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 extraor- dinary, 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 INTRODUCTORY. 5 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. Notwith- standing much benevolence of sentiment towards those who are afflicted with insanity, and much righteous indignation against those 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 ani- mals 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 sym- pathy and active help. But it is not 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 2 6 RESPONSIBILITY IN MENTAL DISEASE. 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 in- stinctively 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 incumbrance; so, in like manner, civilized nations, until recently, thrust out of sight into vile recepta- cles, 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. Notwithstand- ing that it is happily a thing of the past, it will be instructive to inquire from what causes the barba- rous usage sprang: for it was not common to all na- * 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 edi- tion of my work on " Body and Mind." INTRODUCTORY. 7 tions 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 pre- ceded 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 were poetical repre- sentations, 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 su- perstitions 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 doc- trines of Hippocrates. This eminent physician and philosopher express- ly 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 RESPONSIBILITY IN MENTAL DISEASE. 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 observa- tions in his works respecting the symptoms of delir- ium " evidence that clear and correct view of dis- ease 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 hsemorrhoidal discharges in mania, the difficulty of curing madness which commences after the age of forty, and the like. And as there was no super- stition 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 mem- ory. 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 accu- rate notions of madness as a disease, which was to be cured by appropriate medical and moral treatment. INTRODUCTORY. 9 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 man- kind for ever, were lost in the darkness and barba- rism of the middle ages. To trace the causes of this so sad decline would be far beyond my present pur- pose ; suffice the fact that philosophy, which had mounted so high, was for a time sunk so low be- neath 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 and metaphysical mysticism engaged the whole attention of men, who rivalled! one another in verbal disputa- tions, without agreement in the meaning of the terms they used, and in blind worship of the au- thority 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 labori- ously " invoked their own spirits to utter oracles to them ; " wherefore philosophy was little more than a web of unmeaning terms and of empty metaphys- ical subtleties. With this sort of intellectual activity was joined, as the result of the detestable spirit which inspired 10 RESPONSIBILITY IN MENTAL DISEASE. monastic teaching and monastic practice, a harsh religious asceticism, through which the body was looked down upon with contempt, as vile and des- picable, 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 insan- ity have in such an atmosphere of thought and feel- ing ? The conception of it as a disease was impos- sible : 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 person took a religious turn, and his life was a fanatical 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. An- thony, the patriarch of monachism, he had never, in extreme old age, been guilty of washing his feet, * The most learned physicians only put the devil a step fur- ther back, acknowledging "such a preparation and disposition of the body through distemper of humours, which giveth great advantage to the devil to work upon; which distemper being cured by physical drugs and potions, the devil is driven away, and hath no more power over the same bodies." INTRODUCTORY. 11 —he was thought to have reached the ideal of hu- man 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 hu- man estate. It was the natural result of such views of mad- ness 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 dun- geon, 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 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, witch- craft, 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 12 RESPONSIBILITY IN MENTAL DISEASE. of which undoubtedly lay within the domain of madness. Now it is a fact, abundantly exemplified in hu- man 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 depart- ments 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 de- nounced as sacrilegious, to enter upon the study of it by the way of physical research. To have sup- posed that the innermost sanctuary of nature could be so entered through the humble portals of bodily functions, would have been regarded as an un- warrantable 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 heav- enly, and joint partaker of divine immortality. Whosoever had dared to propound such a doctrine INTRODUCTORY. 13 would assuredly have been put to death as a blas- phemer 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. The spirit of metaphysical speculation was scarcely less hostile to physical researches into men- tal function. For when inquirers had struggled successfully out of mere verbal disputation, and had applied themselves to the observation of mental phenomena, the method used was entirely one-sided; it was a system of mental introspection exclusively, each one looking into his own mind and propound- ing as philosophy what he thought he observed there ; the external observation of mind in all its various manifestations, and of the bodily conditions of all mental action, was ignored. When all knowl- edge of mental action was gained in this way by ob- servation of self-consciousness, men naturally formed opinions from their own experience which they applied to the mental states of insane persons ; feel- ing that they themselves had a consciousness of right and wrong, and a power of will to do the right and forbear the wrong, they never doubted that madmen had a like clearness of consciousness and a like power of will—that they could, if they would, control their disorderly thoughts and acts. The 14 RESPONSIBILITY IN MENTAL DISEASE. dungeon, the chain, the whip, and other instruments of punishment were accordingly in constant use as means of coercion ; the result being that exhibitions of madness were witnessed which are no longer to be seen, " because they were not the simple product of malady, but of malady aggravated by misman- agement." What with the theological notion of madness as a work of Satan in the individual, and what with the erroneous views of it subsequently be- gotten of the metaphysical spirit, it came to pass that the barbarous system was abolished only within the memory of men yet living. In sad truth may it be said that, so far' as a knowledge of the nature of mental disease and of the proper mode of its treat- ment is concerned, mankind owe no thanks, but, on the contrary, much error and infinite human suffer- ing, to theology and metaphysics. It was when men recognized insanity as a dis- ease, which, like other diseases, might be alleviated or cured by medical and moral means—when they regained the standpoint which the ancient Grecians had held—that they began the struggle to free themselves in this matter from the bondage of false theology and mischievous metaphysics. But the emancipation is not yet complete. In many quar- ters there is the strongest desire evinced, and the most strenuous efforts are made, to exempt from physical researches the highest functions of mind, and particularly the so-called moral sense and the will; while the old metaphysical spirit still inspires the criterion of responsibility which is sanctioned INTRODUCTORY. 15 and acted upon by courts of justice in cases of in- sanity. If a madman be supposed to know he is doing wrong, or doing that which is contrary to law, when he does some act of violence, he is held to be not less responsible than a sane person. The conclusions reached by the observations of self-con- sciousness in a sane mind are strictly applied to the phenomena of diseased mind; not otherwise than as if it were solemnly enacted that the disorder and violence of convulsions should be measured by the order and method of voluntary movements, and that whosoever, being seized with convulsions, and know- ing that he was convulsed, transgressed that measure, should be punished as a criminal. The unfortunate sufferer, or others on his behalf, might, it is true, innocently argue that the very nature of convulsions excluded the idea of full voluntary control; but the metaphysical intuitionist would rejoin that it was certain from experience that man has a power of control over his movements; that the convulsive movements were a clear proof to all the world that he had not exercised that power; and that his con- vulsions, therefore, were justly punishable as crime. This pathological comparison is scientifically just, and its justness has oftentimes received terribly striking illustration in the effects of the legal cri- terion of responsibility; • for it is certain that in conformity with it many persons unquestionably insane, who have done homicide, not because they loould not, but because they could not, exercise ef- ficient control, have been, and still from time to 16 RESPONSIBILITY IN MENTAL DISEASE. • time are, executed as simple criminals. Harsh and exaggerated as this statement might seem, there is not, I believe, in this or any other civilized country a physician, practically acquainted with the insane, who would not unhesitatingly endorse it. No one now-a-days who is engaged in the treat- ment of mental disease doubts that he has to do with the disordered function of a bodily organ—of the brain. Whatever opinion may be held concern- ing the essential nature of mind, and its independ- ence of matter, it is admitted on all sides that its manifestations take place through the nervous sys- tem, and are affected by the condition of the nerv- ous parts which minister to them. If these are healthy, they are sound; if these are diseased, they are unsound. Insanity is, in fact, disorder of brain producing disorder of mind; or, to define its nature in greater detail, it is a disorder of the supreme nerve-centres of the brain—the special organs of mind—producing derangement of thought, feeling, and action, together or separately, of such degree or kind as to incapacitate the individual for the rela- tions of life.* The opinion that insanity is a disease of the so- called immaterial part of our nature we may look upon as exploded even in its last retreat. The argu- ments that have been adduced in favour of it—first, * Mind may be defined physiologically as a general term de- noting the sum total of those functions of the brain which are known as thought, feeling, and will. By disorder of mind is meant disorder of those functions. INTRODUCTORY. 17 that madness is produced sometimes by moral causes, and, secondly, that it is cured sometimes by moral means—are entirely consistent with the theory of material disease, while the arguments in favour of the materialistic theory are quite inconsistent with the spiritualistic hypothesis, which has the further disadvantage of not being within the range of ra- tional human conception. To the argument that madness is produced some- times by moral causes, which must be admitted, it is sufficient to reply, first, that long-continued or excessive stimulation of any organ does notably in- duce physical disease of it, and that in this respect, therefore, the brain only obeys a general law of the organism; and, secondly, that it is possible to pro- duce experimentally, by entirely physical causes, mental derangement exactly similar to that which is produced by moral causes. There are many facts which would justify us in laying it down as a gen- eralization of inductive mental science, that a state of consciousness may be changed experimentally by agents which produce changes in the molecular con- stitution of those parts of the nervous system which minister to the manifestations of consciousness. Take, for example, the way in which, by the ad- ministration of opium or haschisch, we modify in a remarkable manner a person's conceptions of space and time and of other relations. To the second argument in favour of the immaterial nature of unsound mind, which is founded on the distinctly curative influence of moral treatment, the easy re- 18 RESPONSIBILITY IN MENTAL DISEASE. ply is, that moral means are beneficial in insanity by yielding repose to parts much needing repose, and by stimulating to activity parts much neediug to be active; by yielding repose to morbid thought and feeling, and by rousing into action healthy thought, feeling, and will. The aim of the physician in the treatment of in- sanity is to bring the means at his command to bear, directly or indirectly, on the disordered nerve-ele- ment. But, in striving to do this, he soon learns with how many bodily organs and functions he has really to do. To call mind a function of the brain may lead to much misapprehension, if it be thereby supposed that the brain is the only organ which is concerned in the function of mind. There is not an organ in the body which is not in intimate rela- tion with the brain by means of its paths of nervous communication, which has not, so to speak, a special correspondence with it through internuncial fibres, and which does not, therefore, affect more or less plainly and specially its function as an organ of mind. It is not merely that a palpitating heart may cause anxiety and apprehension, or a disordered liver gloomy feelings, but there are good reasons to believe that each organ has its specific influence on the constitution and function of mind; an influence not yet to be set forth scientifically, because it is exerted on that unconscious mental lif e which is the basis of all that we consciously feel and think. Were the heart of one man to be placed in the body of another it would probably make no difference in INTRODUCTORY. 19 the circulation of the blood, but it might make a real difference in the temper of his mind. So close is the physiological sympathy of parts in the com- monwealth of the body, that it is necessary in the physiological study of mind to regard it as a func- tion of the whole organism, as comprehending the whole bodily life. It has been one of the results of the study of morbid mental action to make clear the importance of recognizing the influence of particular organs upon the constitution and function of mind. Path- ological instances of perturbation of function have yielded intimations which we should have failed to obtain by observation only of the smooth and regu- lar action of the organism in health; and we can now say with the utmost confidence that although the mind may be studied by the psychological method of observing self-consciousness, it cannot be investigated fully by that method alone. As it was in time past, so in time to come error, confusion, and contradiction must flow from so exclusive and insufficient a method. In consequence of the theo- logical and metaphysical views of mind, and of the way in which it was kept isolated from all other subjects of human inquiry, the phenomena of disor- dered mental action were, until quite recently, as much neglected by mental philosophers as the in- sane patients who exhibited them were neglected by those who had the care of them. It seems never to have occurred to metaphysicians that these phenom- ena could have any bearing on a philosophy of 20 RESPONSIBILITY IN MENTAL DISEASE. mind; certainly, had it done so, their exclusive method of inquiry would have proved singularly unfit for the observation of them; and it is only recently, since the nature of insanity has been rec- ognized, and the insane have been treated as suffer- ers from disease, that attempts have been systemat- ically made to use the valuable material which they furnish for the building up of an inductive mental science. Now, however, it may be laid down as an incontestable axiom, that the physiological method of study is essential to a scientific knowledge of mind, to a real acquaintance with its disorders, and to a successful treatment of them. Thus much it seemed necessary to say in order to clear the ground, and to define the position which I shall take in the following pages. But there is something more to be said before I go on to the consideration of the special matters which it is the aim of this book to treat of. Man is not, like some of the lower animals, born with the capacity of at once putting into full play his mental functions; on the contrary, a long and patient education is neces- sary to develop the faculties with which he is en- dowed ; such education being on the physical side, be it noted, a gradual development of the nerve- centres which minister to mind and its manifesta- tions. It costs him much practice before he learns to walk and to talk, while to think accurately is so hard a matter that many persons go to their graves without ever having acquired the power of doing so. When injury or disease has destroyed that INTRODUCTORY. 21 part of the brain which ministers to the expression of ideas in speech, as in the condition of disease known as aphasia, the person must slowly learn again to talk his own language; he is like a child learning to speak, or like one who is learning to talk a foreign language; he must educate another por- tion of brain to do the work which the damaged portion can no longer do. So much in human development being due to education, it is evident that the training which a person undergoes must have a great influence on the growth of his intellect and the formation of his character. What he shall be and what he shall do will be determined in great measure by what has been done to bring into full activity the capabilities of his nature. But great as is the power of educa- tion, it is yet a sternly limited power; it is limited by the capacity of the individual nature, and can only work within this larger or smaller circle of ne- cessity. No training in the world will avail to elicit grapes from thorns or figs from thistles; in like manner, no mortal can transcend his nature; and it will ever be impossible to raise a stable superstruc- ture of intellect and character on bad natural founda- tions. Education can plainly act only, first, within the conditions imposed by the species, and, secondly, within the conditions imposed by the individual or- ganization : can only, in the former case, determine what is predetermined in the organization of the nervous system and of the bodily machinery in con- nection with it—cannot, for example, ever teach a 3 22 RESPONSIBILITY IN MENTAL DISEASE. man to fly like a bird, or see like an eagle, or run like an antelope; can only again, in the latter case, make actual the potentialities of the individual na- ture—cannot make a Socrates or a Shakspeare of every being born into the world. There was a foundation of fact, though not the fact of which he dreamed, in the speculations of the astrologer who believed that by observation of the star in the ascendant at the time of a mortal's birth he might predict his destiny. He was conscious of a fate in human life, but he failed to see that it was the fate made for a man by his inheritance. No power of microscope or chemistry, no power which science can make use of, will enable us to distinguish the human ovum from the ovum of a quadruped; yet it is most certain that the former has inherited in its nature something whereby it developes under suitable conditions into the form of man, and that the latter has in like manner inherited something whereby it developes under suitable conditions into the form of a quadruped. Not only has the human ovum this destiny of the species in its nature, but each particular ovum has an individual inheritance which makes for it an individual destiny. Men are in much alike, but each individual differs in some respects from any other individual who now exists, or, it may be con- fidently assumed, ever has existed or ever will exist. And this is not a difference which is due to educa- tion or circumstances, but a fundamental difference of nature which neither education nor circumstances INTRODUCTORY. 23 can eradicate. Let two persons be placed from birth in the same circumstances and subjected to the same training, they wrould not in the end have exactly the same pattern and capacity of mind any more than they would have the same pattern of face: each is under the dominion of the natural law of evolution of the antecedents of which he is the consequent, and could no more become the other than an oak could become an elm if their germs were planted in the same soil, warmed by the same sun, and watered by the same showers : each would display variations which by the operation of natural selection would issue finally in distinct varieties of character. There is a destiny made for a man by his ancestors, and no one can elude, were he able to attempt it, the tyranny of his organization. The power of hereditary influence in determin- ing an individual's nature, which when plainly stated must needs appear a truism, has been more or less distinctly recognized in all ages. Solomon proclaimed it to be the special merit of a good man that he leaves an inheritance to his children's chil- dren ; on the other hand, it has been declared that the sins of the father shall be visited upon the chil- dren unto the third and fourth generations. Not that the failing of the father shall necessarily show in the children either in the same form or in any recognizable form ; it may undergo transformation in the second generation, or may be entirely latent in it, not coming to the surface in any form until the third or fourth generation. But it will run on 24: RESPONSIBILITY IN MENTAL DISEASE. in the stream of family descent, sometimes appear- ing on the surface, sometimes hidden beneath it, un- til, on the one hand, it is either neutralized by the beneficial influences of wise intermarriages, or, on the other hand, reaches a pathological evolution which entails the decay and extinction of the family. It was a proverb in Israel that when the fathers have eaten sour grapes the children's teeth are set on edge; and it was deemed no marvel that those whose fathers had stoned the prophets should reject Him who was sent unto them—" Ye are the children of those who stoned the prophets." The institution of caste among the Hindoos appears to have owed its origin to a recognition of the large play of he- reditary influence in human development; and that dread, inexorable destiny which has so great and grand a part in Grecian tragedy, and which Grecian heroes manfully contended against, although fore- knowing that they were inevitably doomed to de- feat, was in some degree an embodiment of the deep feeling of the inevitable dependence of a man's present being on his antecedents in the past. " Bless not thyself only," says the author of the Religio Medici, " that thou wert born in Athens; but, among thy multiplied acknowledgments, lift up one hand to heaven, that thou wert born of honest parents, that modesty, humility, and veracity, lay in the same egg, and came into the world with thee. From such foundations thou may'st be bappy in a virtuous precocity, and make an early and long INTRODUCTORY. 25 walk in goodness; so may'st thou more naturally feel the contrariety of vice unto nature, and resist some by the antidote of thy temper." When we observe what care and thought men give to the se- lective breeding of horses, cows, and dogs, it is as- tonishing how little thought they take about the breeding of their own species: perceiving clearly that good or bad qualities in animals pass by heredi- tary transmission, they act habitually as if the same laws were not applicable to themselves; as if men could be bred well by accident; as if the destiny of each criminal and lunatic were determined, not by the operation of natural laws, but by a special dis- pensation too high for the reach of human inquiries. When will man learn that he is at the head of na- ture only by virtue of the operation of natural laws ? When will he learn that by the study of these laws and by deliberate conformity to them he may become the conscious framer of his own des- tiny ? Notwithstanding that the influence of hereditary antecedents upon the character of the individual has been admitted by all sorts and conditions of men, its important bearing upon moral responsibility has not received the serious consideration which it deserves. Laws are made and enforced on the supposition that all persons who have reached a certain age, arbitra- rily fixed as the age of discretion, and are not de- prived of their reason, have the capacity to know and obey them; so that when the laws are broken, the punishment inflicted is in proportion to the nature 26 RESPONSIBILITY IN MENTAL DISEASE. of the offence and not to the actual moral respon- sibility of the individual. The legislator can know nothing of individuals ; he must necessarily assume a uniform standard of mental capacity so far as a knowledge of right and wrong, and of moral power so far as resistance to unlawful impulses, are con- cerned ; exceptions being made of children of tender age and of persons of unsound mind. There can be no question, however, that this as- sumption is not in strict accordance with facts, and that there are in reality many persons who, without being actually imbecile or insane, are of lower moral responsibility than the average of mankind ; they have been taught the same lessons as the rest of mankind, and have a full theoretical knowledge of them, but they have not really assimilated them; the principles inculcated never gain that hold of their minds which they gain in a sound and well- constituted nature. After all that can be said, an individual's nature will only assimilate, that is, will only make of the same kind with itself, what is fitted to further its special development, and this it will by a natural affinity find in the conditions of its life. To the end of the chapter of life the man will feel, think, and act according to his kind. The wicked are not wicked by deliberate choice of the advantages of wickedness, which are a delusion, or of the pleasures of wickedness, which are a snare, but by an inclination of their natures which makes the evil good to them and the good evil: that they choose the gratification of a present indulgence, in INTRODUCTORY. 27 spite of the chance or certainty of future punish- ment and suffering, is often a proof not only of a natural affinity for the evil, but of a deficient under- standing and a feeble will. The most sober and ex- perienced prison officials are driven sooner or later to a conviction of the hopelessness of reforming ha- bitual criminals. " The sad realities which I have contemplated," says Mr. Chesterton, " compel me to aver that at least nine-tenths of habitual depreda- tors have no desire or intention to forsake their guilty course. They love the vices in which they have revelled. . . . ' Lord, how I do love thieving; if I had thousands I would still be a thief,' I heard a youth exclaim on one occasion." * It was the opinion of Plato that the wicked owe their wickedness to their organization and educa- tion, so that not they, but their parents and instruct- ors should be blamed ; and other eminent philoso- phers, among whom Hippocrates is included, have maintained that there was no vice but was the fruit of madness. '* No man doth sin, but he is pos- sest in some degree ; it is good divinity," says the learned Casaubon.f To uphold such a doctrine now-a-days would be thought a perilous thing to society, as removing from the wicked man the salutary fear of the penal consequences of his actions, which operates to turn him from his * Revelations of Prison Life. By G. L. Chesterton. f A Treatise concerning Enthusiasme, as it is an Effect of Nature, but is mistaken by many for either Divine Inspiration or Diabolical Possession. By Meric Casaubon, D. D. 28 RESPONSIBILITY IN MENTAL DISEASE. wickedness and to make him do that which is lawful and right. And yet, if the matter be con- sidered deeply, it may appear that it would, per- haps, in the end make little difference whether the offender were sentenced in anger and sent to the seclusion of prison, or were sentenced more in sorrow than in anger, and consigned to the same sort of seclusion under the name of an asylum. The change would probably not lead either to an increase or to a decrease in the number of crimes committed in a year. It will be said, however, that if crime were con- sidered to be the fruit of madness, it would be wrono- to punish an offender at all; he ought rather to be pitied and kindly cared for. But do we not in reality punish insanity, however little we may wish to do so ? The measures which are necessarily adopted for the proper care of the insane and for the protection of others are a punishment. It is a punishment, or at any rate it is the infliction of what they for the most part regard as grievous suf- fering, to deprive them of liberty by confining them in asylums and to subject them to the discipline of such establishments. Moreover, it is unquestion- ably the best treatment to induce an insane person to work if he is fit to work, and there can be little doubt that there would be more recoveries from insanity than there are in our asylums if more work could be systematically enforced in them. Indeed, it is not improbable that the old, harsh, and inhu- mane system of treating the insane was effectual in INTRODUCTORY. 29 bringing back to their senses some few who, under the modern indulgent system, have no motives ex- cited in their minds sufficiently powerful to induce them to make those efforts at self-control which are often the beginning of recovery. In like manner, though the criminal might be compassionated, it would still be necessary to deprive him of the power of doing further mischief ; society has clear- ly the right to insist on that being done; and though he might be kindly cared for, the truest kindness to him and others would still be the en- forcement of that kind of discipline which was best fitted to bring him, if possible, to a healthy state of mind, even if it were hard labour within the meas- ure of his strength. If we are satisfied that our prison-system is the best that can be devised for the prevention of crime and the reformation of the criminal, we may rest satisfied that it is the best treatment for the sort of insanity from which criminals suffer. No fear therefore of the prac- tical ill consequences to society need deter us from looking on criminals as the unfortunate victims of a vicious organization and a bad education. But what in this age it would seem right that we should do, is to get rid of the angry feeling of retaliation which may be at the bottom of any judicial punishment, and of all penal measures that may be inspired by such feeling. Society having manufactured its criminals has scarcely the right, even if it were wise for its own sake, to treat them in an angry spirit of vengeance. 30 RESPONSIBILITY IN MENTAL DISEASE. Not until comparatively lately has much atten- tion been given to the way in which criminals are produced. It was with them much as it was at one time with lunatics : to say of the former that they were wicked, and of the latter that they were mad, was thought to render any further explanation un- necessary and any further inquiry superfluous. It is certain, however, that lunatics and criminals are as much manufactured articles as are steam-engines and calico-printing machines, only the processes of the organic manufactory are so complex that we are not able to follow them. They are neither acci- dents nor anomalies in the universe, but come by law and testify to causality; and it is the business of science to find out what the causes are and by what laws they work. There is nothing accidental, nothing supernatural, in the impulse to do right or in the impulse to do wrong; both come by inherit- ance or by education; and science can no more rest content with the explanation which attributes one to the grace of Heaven and the other to the malice of the devil, than it could rest content with the ex- planation of insanity as a possession by the devil. The few and imperfect investigations of the per- sonal and family histories of criminals which have yet been made are sufficient to excite some serious reflections. One fact which is brought strongly out by these inquiries is that crime is often heredi- tary ; that just as a man may inherit the stamp of the bodily features and characters of his parents, so he may also inherit the impress of their evil pas- INTRODUCTORY. 31 sions and propensities: of the true thief as of the true poet it may be indeed said that he is born, not made. This is what observation of the phenomena of hereditary action would lead us to expect; and although certain theologians, who are prone to square the order of nature to their notions of what it should be, may repel such a doctrine as the heritage of an immoral in place of a moral sense, they will in the end find it impossible in this matter, as they have done in other matters, to con- tend against facts. To add to their misfortunes, many criminals are not only begotten, and con- ceived, and bred in crime, but they are instructed in it from their youth upwards, so that their origi- nal criminal instincts acquire a power which no subsequent efforts to produce reformation will ever counteract. All persons who have made criminals their study, recognize a distinct criminal class of beings, who herd together in our large cities in a thieves' quarter, giving themselves up to intemperance, riot- ing in debauchery, without regard to marriage ties or the bars of consanguinity, and propagating a criminal population of degenerate beings. For it is furthermore a matter of observation that this crimi- nal class constitutes a degenerate or morbid variety of mankind, marked by peculiar low physical and mental characteristics. They are, it has been said, as distinctly marked off from the honest and well- bred operatives as " black-faced sheep are from other breeds," so that an experienced detective officer or 32 RESPONSIBILITY IN MENTAL DISEASE. prison official could pick them out from any promis- cuous assembly at church or market.* Their family likeness betrays them as fellows " by the hand of nature marked, quoted and signed to do a deed of shame." They are scrofulous, not seldom deformed, with badly-formed angular heads ; are stupid, sullen, sluggish, deficient in vital energy, and sometimes afflicted with epilepsy. As a class, they are of mean and defective intellect, though excessively cunning, and not a few of them are weak-minded and imbecile, f The women are ugly in features, and without grace of expression or movement. The children, who become juvenile criminals, do not evince the educational aptitude of the higher indus- trial classes: they are deficient in the power of attention and application, have bad memories, and make slow progress in learning; many of them are weak in mind and body, and some of them actually imbecile. Mr. Bruce Thomson, who in his official capacity as surgeon to the General Prison of Scot- * The Hereditary Nature of Crime. By J. B. Thomson, Journal of Mental Science, vol. xv., p. 487. t The mendicant thieves are well known to prison officials as a class of persons of weak intellect, who tramp through the country, prowling about the different houses, and begging or stealing as the opportunity offers; and it is by them that arson, rape, and other crimes are often perpetrated. In the county of Cumberland, a few years ago, the practice of committing them to prison as soon as they crossed the border was enforced. The direct result was a considerable increase in the number of ad- missions into the county asylum, to which they were trans- ferred from gaol as being persons of imbecile or unsound mind. INTRODUCTORY. 33 land had observed thousands of prisoners, declared that he had not known one to exhibit any aesthetic talent; he had never seen a pen-sketch, a clever poem, or an ingenious contrivance produced by one of them.* Habitual criminals are, he says, without moral sense—are true moral imbeciles ; their moral insensibility is such that in the presence of tempta- tion they have no self-control against crime; and among all the murderers he had known, amounting to nearly five hundred, only three could be ascer- tained to have expressed any remorse. He quotes among other testimonies to a like effect the opinion of a medical friend, a shrewd observer of men, much conversant with* lunacy, and having had a long ex- perience among prisoners, who declared himself mainly impressed with their extreme deficiency or perversion of moral feeling, the strength of the evil propensities of their natures and their utter imprac- ticability. " In all my experience I have never seen such an accumulation of morbid appearances as I witness in the post mortem examinations of the prisoners who die here. Scarcely one of them can be said to die of one disease, for almost every organ of the body is more or less diseased; and the wonder to me is that life could have been supported in such a diseased frame. Their moral nature seems equally diseased with their physical frame; and whilst their mode of life in prison reanimates their physical * In this, however, his experience must have been singular; for other prison officers have not observed these deficiencies. 34 RESPONSIBILITY IN MENTAL DISEASE. health, I doubt whether their minds are equally benefited, if improved at all. On a close acquaint- ance with criminals, of eighteen years' standing, I consider that nine in ten are of inferior intellect, but that all are excessively cunning." * We may accept then the authority of those who have studied criminals, that there is a class of them marked by defective physical and mental organiza- tion, one result of their natural defect, which really determines their destiny in life, being an extreme deficiency or complete absence of moral sense. In addition to the perversion or entire absence of moral sense, which experience of habitual criminals brings prominently out, other important facts disclosed by the investigation of their family histories are, that a considerable proportion of them are weak-minded or epileptic or become insane, or that they spring from families in which insanity, epilepsy, or some other neurosis exists, and that the diseases from which they suffer and of which they die are chiefly tuber- cular diseases and diseases of the nervous system. Crime is a sort of outlet in which their unsound tendencies are discharged; they would go mad if they were not criminals, and they do not go mad because they are criminals. * " As in all families or races where physical degeneration is found, so among the criminal class we have very often ab- normal states—such as spinal deformities, stammering, imper- fect organs of speech, club-foot, cleft-palate, hare-lip, deafness, congenital blindness, paralysis, epilepsy, and scrofula. These usually accompany congenital weakness of mind."—Mr. Bruce Thomson, loc. cit. INTRODUCTORY. 35 Crime is not then in all cases a simple affair of yielding to an evil impulse or a vicious passion, which might be checked were ordinary control exer- cised ; it is clearly sometimes the result of an actual neurosis which has close relations of nature and de- scent to other neuroses, especially the epileptic and the insane neuroses; and this neurosis is the phys- ical result of physiological laws of production and evolution. No wonder that the criminal psychosis, which is the mental side of the neurosis, is for the most part an intractable malady, punishment being of no avail to produce a permanent reformation. The dog returns to its vomit and the sow to its wal- lowing in the mire. A true reformation would be the re-forming of the individual nature; and how can that which has been forming through genera- tions be re-formed within the term of a single life ? Can the Ethiopian change his skin or the leopard his spots ? Thus then when we take the most decided forms of human wrong-doing, and examine the causes and nature of the moral degeneracy which they evince, we find that they are not merely subjects for the moral philosopher and the preacher, but that they rightly come within the scope of positive scientific research. The metaphysical notion of man as an abstract be- ing endowed with a certain fixed moral potentiality to do the right and eschew the wrong, is as little ap- plicable to each human being born into the world as the notion of a certain fixed intellectual power would be applicable to each being, whether of good men- 36 RESPONSIBILITY IN MENTAL DISEASE, tal capacity, imbecile or idiot. There are, as natu- ral phenomena, manifold gradations of understand- ing from the highest intellect to the lowest idiocy, and there are also, as natural phenomena, various degrees of moral power between the highest energy of a well-fashioned will and the complete absence of moral sense. Nor are intellect and moral power; so dependent mutually as necessarily to vary to- gether, the one increasing and decreasing as the other increases and decreases: experience proves conclusively that there may be much intellect with little morality and much morality with little intel- lect. There is a borderland between crime and insan- ity, near one boundary of which we meet with something of madness but more of sin, and near the other boundary of which something of sin but more of madness. A just estimate of the moral responsi- bility of the unhappy people inhabiting this border- land will assuredly not be made until we get rid of the metaphysical measure of responsibility as well as of the theological notion that vices and crimes are due to the instigation of the devil, and proceed by way of observation and induction to sound general- izations concerning the origin of the moral senti- ments, the laws of their development, and the causes, course and varieties of moral degeneracy. Here as in other departments of nature our aim should be the discovery of natural laws by patient interroga- tion of nature, not the invention of theories by in- voking our own minds to utter oracles to us. It INTRODUCTORY. 37 must be received as a scientific axiom that there is no study to which the inductive method of research is not applicable ; every attempt to prohibit such re- search by authority of any kind must be withstood and repelled with the utmost energy as a deadly at- tack upon the fundamental principle of scientific in- quiry. With a better knowledge of crime we may not come to the practice of treating criminals as we now treat insane persons, but it is probable that we shall come to other and more tolerant sentiments, and that a less hostile feeling towards them, derived from a better knowledge of defective organization, will beget an indulgence at any rate towards all doubtful cases inhabiting the borderland between in- sanity and crime ; in like manner as within living memory the feelings of mankind with regard to the insane have been entirely revolutionized by an in- ductive method of study. There are advantages in recognizing a just prin- ciple even when events are not ripe enough for its application, when it looks Utopian and excites the derision of practical men ; for it slowly modifies feelings and ideas, acts as a solvent of prejudices, and, notwithstanding seemingly insuperable difficul- ties, tends by hardly perceptible degrees to its real- ization in action. The sincere recognition of it is, as it were, a prophecy which finally brings about its own fulfilment: the Utopian idea of one age becom- ing often the common-place idea of a succeeding age. Note.—The following account is quoted by Casaubon in his Treatise concerning Enthusiasm from Josephus Acosta. I ap- 4 38 RESPONSIBILITY IN MENTAL DISEASE. pend it as a striking illustration of the way in which madness was sometimes innocently dealt with in the days of Acosta :— "There was (saith Acosta) in this very Kingdome of Peru (where himself was once Propositus Generalis), a man of great esteem in those dayes, a learned Divine and Professor (or Doc- tor) of Divinity. The same also accounted religious and ortho- dox : yea in a manner, the oracle, for his time, of this other world (America). This man being grown familiar with a cer- tain muliercula (or, plain woman), which as another Philumena or Maximilla that Montanus carried about boasted of her self, that she was taught by an Angel certain great mysteries; and would also fall (or feign it at least) into trances and raptures, which carried her quite beside herself: he was at last so be- witched and captivated by her, that he did not stick to referre unto her concerning highest points of Divinity: entertain her answers, as oracles; blaze her abroad, as a woman full of reve- lations, and very dear unto God; though in very deed a woman, as of mean fortune, so of as mean a capacitie otherwise, except it were to forge lies. This woman, then, whether really possest of the Devil, which is most likely, because of those ecstasies; or whether she acted it with art and cunning, as some learned men suspected; because she told him strange things concerning him- self, that should come to passe, which his phansie, made yet greater: he did certainly the more willingly apply himself unto her, to be her disciple, whose ghostly Father he had been be- fore. To be short; he came at last to that, that he would take upon himself to do miracles, and did verily think that he did, when in very deed there was no ground at all for any such thought. For which, and for certain propositions contrary to the Faith, he had received from his Prophetesse, he was at last, by order of the Judges of the holy Inquisition, to the great as- tonishment of this whole kingdome, apprehended and put in prison: where for the space of five years he was heard, tolerated, examined, until at last his incomparable pride and madnesse was made known unto all men. For whereas he pretended with all possible confidence and pertinacity, that he had a private angel, of whom he learned whatsoever he desired; yea that he had been intimate with God Himself, and conferred with him personally; he would utter such fopperies as none would believe INTRODUCTORY. 39 could proceed from any that were not stark mad: yet in very truth, the man was in perfect sense, as to soundnesse of brain ; as perfect as I myself can think myself, at this time now writ- ing of him. Very sadly and soberly therefore he would affirm, that he should be a King: yea, and Pope too; the Apostolical See being translated to those parts : as also that holinesse was granted unto him above all angels, and heavenly hosts, and above all apostles: yea that God had made profer unto him of hypostatical union, but that he refused to accept of it. More- over, that he was appointed to be Redeemer of the world, as to matter of efficacy: which Christ, he said, had been no further then to sufficiency only. That all ecclesiastical estate was to be abrogated; and that he would make new laws, plain and easie, by which the Coelibatus (or restraint of marriage) of Clergie- men should be taken away, multitude of wives allowed, and all necessity of confession avoided. These things, and other things of that nature he would affirme with such earnest confidence, as we were all amazed, that any man could be in his right wits that held such opinions. In fine, after the examination of his actions, and heretical propositions, to the number of a hun- dred and ten and upwards, either heretical all, or at least not agreeable to the sound doctrine of the Church ; as the manner of that High Court is, we were appointed to dispute with him, if possibly we might reduce him to sobriety. We were three in all, besides the Bishop of Quinto, that met before the Judges about it. The man being brought in, did plead his cause with that liberty and eloquence of speech, that I stand amazed to this day, that mere pride should bring a man unto this. He ac- knowledged that his Doctrine, because above all humane reason, could not be proved but by Scripture and Miracles. As for Scripture; that he had proved the truth of it by testimonies taken from thence, more clear and more pregnant than ever Paul had proved Jesus Christ to be the true Messias by. As for miracles; that he had done so many and so great, that the Res- urrection of Christ itself was not a greater Miracle. For that he had been dead verily and truly, and was risen again; and that the truth of it had been made apparent unto all. All this while, though he had never a book in the prison, so that even his Breviary was taken away from him, he did quote places of 40 RESPONSIBILITY IN MENTAL DISEASE. Scripture out of the Prophets, the Apocalyps, the Psalms, and other books, so many and so long, that his very memory caused great admiration. But these places he did so apply to his phansies, and did so allegorize them, that any that heard him must needs either weep or laugh. But lastly, if we did yet re- quire miracles, that he was ready to be tried by them. And this he spake as either certainly mad himself, or accounting us all mad. For that by revelation it was come to his knowledge, he said, that the Serenissimus John of Austria was vanquished by the Turks upon the seas: that Philip the most puissant king of Spain, had lost most part of his kingdom: that a Council was held at Rome, about the deposition of Pope Gregory, and another to be chosen in his place. That he told us these things, whereof we had certain intelligence, because we might be sure that they could not be known unto himself, but by immediate divine revelation. All which things, though they were so false that nothing could be more, yet still were they affirmed by him, as certainly known unto us. But at last, having disputed with him two dayes to no effect at all, being led out with some others (as the fashion is in Spain) to be made a publick Spectacle; he ceased not to look up to Heaven, expecting (as it seems the Devil had promised him,) that fire would come to consume both Inquisitors and spectators all. But in very deed, no such fire came from above; but a flame came from below, which seized upon this pretended King, and Pope, and Redeemer, and new Law-giver, and quickly did reduce him into ashes." CHAPTER II. THE BORDERLAND. No distinct line of demarcation between sanity and insanity— Continuity in nature—The borderland—The insane tem- perament—Transformation of nervous diseases—Kinship between insanity and epilepsy, neuralgia, chorea, dipsomania —Functional and organic diseases of the brain—Hereditary predisposition: its pathological evolution through genera- tions—Originalities of idea, feeling and impulse in con- nection 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. It would certainly be vastly convenient, and would save a world of trouble, if it were possible to draw a hard and fast line, and to declare that all persons who were on one side of it must be sane and all persons who were on the other side of it must be insane. But a very little consideration will show how vain it is to attempt to make such a divi- sion. That nature makes no leaps, but passes from one complexion to its opposite by gradations so gen- tle that one shades imperceptibly into another, and 41 42 RESPONSIBILITY IN MENTAL DISEASE. no one can fix positively the point of transition, is a sufficiently trite observation. Nowhere is this more true than in respect of sanity and insanity; it is unavoidable therefore that doubts, disputes and per- plexities should arise in dealing with particular cases. The matter is made worse by the strong tend- ency which there is in the human mind to believe that there are actual divisions in nature correspond- ing with the more or less arbitrary divisions which are necessarily made in the acquisition and classifi- cation of knowledge; whence comes either an aver- sion, conscious or unconscious, to admit frankly the existence of intermediate instances which cannot be duly marshalled in distinct classes, or a disposition so to exaggerate resemblances and to overlook dif- ferences as to force the rebellious instances into one class or another. It is vain, however, to shut our eyes to facts, however inconvenient they may be to our systems of classification; and, in very truth, these cases that will not be classified, these inter- mediate steps, are often of excellent use, if rightly appreciated, in breaking down the barriers of arti- ficial distinctions and bridging the gaps between them. Opinions that might seem almost as opposite as heaven and hell, and for which men fight unto death, have really a bridge of connection, though it may be a bridge of many arches, which their furi- ous defenders fail to see. It would be no exaggera- tion to declare that there is so much in common be- tween a most virtuous and a most vicious man as THE BORDERLAND. 43 would render it impossible to attain to a scientific understanding of the nature of the one without a scientific understanding of the nature of the other. In the formation and verification of our generaliza- tions it is almost as incumbent upon us to look care- fully to the intermediate instances between two classes as it is not to overlook opposing instances. It is of great importance then to recognise a borderland between sanity and insanity, and of greater importance still, not resting content with a mere theoretical recognition of it, to study care- fully the doubtful cases with which it is peopled. The bearing of such study on our opinions, though at first it may seem to be to confound well-estab- lished distinctions, and to make uncertain what be- fore seemed certain, cannot fail in the end to be most beneficial. Assuredly it is a fact of experi- ence that there are many persons who, without be- ing insane, exhibit peculiarities of thought, feeling and character which render them unlike ordinary beings and make them objects of remark among their fellows. They may or may not ever become actually insane, but they spring from families in which insanity or other nervous disease exists, and they bear in their temperament the marks of their peculiar heritage : they have in fact a distinct neu- rotic temperament—a certain neurosis, and some of them a more specially insane temperament—an in- sane neurosis. We are, it is true, yet without any exact knowl- edge of the ways of hereditary action, but there can 44 RESPONSIBILITY IN MENTAL DISEASE. be no doubt of the general fact that individuals do sometimes inherit a positive tendency to a particular nervous disease from which one or other of their parents or ancestors has suffered. The son of an insane person carries in his organization a distinctly greater liability to an outbreak of insanity under the ordinary conditions of life than the son of per- fectly sane parents; in saying that he has a heredi- tary predisposition to insanity we express this fact which is attested by general experience. Another fact of observation is that the offspring of persons who have suffered from some nervous disease fre- quently inherit a liability to the attack of some other nervous disease than that which has given them their neurotic heritage: there is a kinship be- tween nervous diseases by virtue of which it comes to pass that they undergo transformation through generations. The two diseases most closely related in this way are insanity and epilepsy; the descendant of an epi- leptic parent being almost if not quite as likely to become insane as to become epileptic, and one or other of the descendants of an insane parent not unfrequently suffering from epilepsy. In like man- ner neuralgia in the parent may manifest itself in the offspring in the form of a tendency to insanity, and every experienced physician knows that if he meets in practice with a case of violent neuralgia, which occurs from time to time in an obscure way, without any discoverable morbid cause, he may pred- icate the existence of insanity in the family with THE BORDERLAND. 45 almost as great confidence as if the patient were actually insane. How it is we know not, but so it is that a certain form of neuralgia owes its origin mainly to a neurotic inheritance. Chorea, again, which has been described fanci- fully as " an insanity of the muscles," is a nervous disease which exhibits sometimes a close relation of descent to insanity or epilepsy; and in children de- scended from families in which there has been much insanity we meet occasionally with diseased phe- nomena that seem to be hybrids between chorea and epilepsy, or between chorea and insanity, and which pass finally into one of these more definite ruts of convulsive action. It may be remarked here by the way that in calling epilepsy and chorea convulsive diseases, what we mean is, that they are diseases in which the nerve centres that preside over move- ments, being deranged, have lost that co-ordination and subordination which are manifest in their healthy functions, and display irregular, perverted and violent action. In like manner insanity might truly be described as a chorea or convulsive disease of the mind, the derangement being in nerve centres whose functions are not motor but mental, and whose derangements therefore display themselves in convulsions not of the muscles but of mind. Hence it is that instances occasionally present themselves in which the disor- der is transferred suddenly from one set of nerve centres to another, the old symptoms ceasing and quite a new order of symptoms supervening. Thus, 46 RESPONSIBILITY IN MENTAL DISEASE. a severe neuralgia disappears and the patient is at- tacked with some form of madness, the morbid con- ditions of perverted function having been trans- ferred from the sensory centres to the mind centres; when the madness has passed away the neuralgia may return. Again, convulsions cease and insanity occurs, the transference being from the motor cen- tres to the mind centres ; or, conversely, the appear- ance of convulsions may be the determination of an attack of insanity. Instances like these indicate that the kind of morbid change which is the phys- ical condition of deranged function in the sensory and motor nerve centres is similar to that which is the condition of morbid function in the mind cen- tres ; however that may be, they certainly warrant the conclusion that disease of mind is a derangement which is nowise metaphysical, but one strictly com- parable with such other nervous disorders as neural- gia and convulsions. If we once for all clearly realize this just pathological conception of the na- ture of mental derangement, it will deliver us from a multitude of vain speculations, and we shall find it of essential use in our endeavours to arrive at cor- rect opinions with regard to the responsibility of insane persons. There is another degenerate condition, if it be not actual disease, which has close relation to insan- ity, either as cause or effect—namely, dipsomania. A host of facts might be brought forward to prove that drunkenness in parents, especially that form of drunkenness known as dipsomania, which breaks out THE BORDERLAND. 47 from time to time in uncontrollable paroxysms, is a cause of idiocy, suicide or insanity in their offspring. It would seem to be truly a nervous disease, a kind of insanity; in its outbreaks it displays the periodici- ty which is a common character of nervous diseases; and it exhibits its close kinship to insanity not only by the fact that when occurring in one generation it may become the occasion of mental derangement or suicide in the next generation, but conversely by the fact that insanity in the parent may occasion dipso- mania in the offspring. In pointing out the relations between mental and other nervous diseases, I have noticed instances of so-called functional diseases only, that is, diseases in which after death we fail to find, by the means of investigation which we have at our command, any actual morbid changes. Not that physical changes do not presumably exist in the intimate elements of structure to which our senses have not yet gained access: we believe confidently that as by means of the spectroscope we have discovered facts which, before its invention, were quite beyond our ken; or as by means of the telescope we have discovered stars which, without its help, would have remained unknown to us; so the time will come when by the invention of improved instruments of research the insensible movements of molecules will be as open to observation as are the molar movements of the heavens, and when those that come after us will not fail to discover the physical causes of derangements which we are now constrained to call functional. 48 RESPONSIBILITY IN MENTAL DISEASE. It is with so-called functional diseases, such as epilepsy, chorea, neuralgia, that insanity displays the most marked relationship, not with organic diseases such as apoplexy and softening of the brain, in which we are able to detect visible deterioration of the structure of the nerve centres. The reason of this probably is that while the functional diseases are strictly and essentially nervous, the organic diseases are rather due primarily to disease of other tissues. Apoplexy, for example, is caused by degeneration of the walls of the blood-vessels, and consequent rupture of them is, as it were, an inundation of the adjacent territory through the giving way of the banks of the stream, the destruction of nerve- structure being secondary to the effusion of blood. Softening of the brain again is probably owing to defective nutrition as much as to any inherent weak- ness of nerve element. Certain it is that those morbid changes, whatever they are, in the intimate elements of the nervous system, which are the con- ditions of mental derangement, are much more closely allied to the similarly obscure morbid condi- tions of epilepsy, neuralgia, and chorea, than they are to the visible and palpable injury of structure which we meet with in the so-called organic dis- eases. It is hardly necessary to point out that those who inherit a tendency or predisposition to insanity are, other things being equal, less favourably placed in the struggle of life than those who are free from such tendency; their nervous centres are less stable, THE BORDERLAND. 49 and more likely therefore to fall into derangement of function ; and when the equilibrium of them has been disturbed, they do not, like perfectly soundly constituted centres, return easily after a short time to their old equilibrium, but are apt to find a more stable equilibrium in degenerate function; just as in the breaking up of highly complex organic com- pounds the components fall readily into more simple and stable combinations, until the human body, as it goes through the successive stages of putrefaction, is reduced at last to carbonic acid, water and am- monia. Not all the maxims of all the philosophies nor all the lessons of all the religions which the world has seen, will annihilate this physical impulse, though they may succeed in some instances in coun- teracting it. There are of course many degrees of hereditary predisposition: in some persons it is so slight that no one would suspect its existence, while others carry the sure marks of it in their countenance, manner and conversation, presenting peculiarities sufficiently characteristic to justify the description of them under the name of the insane temperament or the insane neurosis. Not that every member of a family in which there is nervous or mental disease presents ths insane temperament; on the contrary, some persons who have had an insane father or mother do not exhibit any marked mental or bodily peculiarities. But although the hereditary neurosis does not display itself in them, it may still be there latent or dormant, not dead but sleeping, and may 50 RESPONSIBILITY IN MENTAL DISEASE. appear in a decided form in the next generation. The more closely we study mental derangements and their causation, the more clearly we perceive the influence of hereditary peculiarities, even though these may seem to be of a trivial kind, in the pro- duction of more marked neuropathic states in the offspring. "What can possibly have been the cause ?" is the question again and again asked of the physician by an anxious father or mother, who all the while carries in his physiognomy, gestures, or habits of thought and feeling the unmistakeable evidence of the cause. Were the physician to an- swer briefly and sincerely, the honest reply would be—" A pathological evolution of your nature." When the insane temperament has been devel- oped in its most marked form, we must acknowledge that the hereditary predisposition has assumed the character of deterioration of race, and that the in- dividual represents the beginning of a degeneracy which, if not checked by favourable circumstances, will go on increasing from generation to generation and end finally in the extreme degeneracy of idiocy. With the occurrence of idiocy there is happily the extinction of the degenerate variety, for with it come impotence and sterility. Beneath and beyond the little span of nature which lies within the reach of our faculties, with which our senses bring us into relation, there is a power which inspires evolution on earth, taking good care that its work is done, no matter at what cost in time, in prodigality of life, in individual suffering, animal or human. THE BORDERLAND. 51 Let it be observed now that in its less marked forms the insane neurosis is by no means the un- mixed evil which it might on a superficial considera- tion appear to be. When we look into the matter it is truly remarkable how much mankind has been indebted for its originating impulses and for special displays of talent, if not of genius, to individuals who themselves or whose parents have sprung from families in which there has been some predisposition to insanity. Such persons are apt to seize on and pursue the bypaths of thought which have been overlooked by more stable intellects, and so, by throwing a side light upon things, to discover un- thought of relations. One observes this tendency of mind even in those of them who have no particu- lar genius or talent; for they have a novel way of looking at things, do not run in the common groove of action or follow the ordinary routine of thought and feeling, but discover in their remarks a certain originality and perhaps singularity, sometimes at a very early period of life. This is illustrated now and then by a remarkable aptitude for punning and by strange quirks and cranks of fancy, such as a person not so peculiarly gifted might die before he could invent. Notable again is the emancipated way in which some of them discuss, as if they were problems of mechanics, objects or events round which the associations of ideas and feelings have thrown a glamour of conventional sentiment. In regard to most beliefs they are usually more or less heterodox or heretical, though often not constant, 52 RESPONSIBILITY IN MENTAL DISEASE. being apt to swing round suddenly from one point to a quite opposite point of the compass of belief. It is a fact too that they frequently display re- markable aesthetic feeling and special artistic talents and aptitudes. An intensity of feeling and energy characterizes them: inspired with strong faith in the opinions which they adopt, they exhibit much zeal and energy in the propagation of them, and so become useful as reformers; they are possessed with a degree of fanaticism which bears them on to their end, reckless of the most formidable ob- stacles. A person of large, calm and deep intellect, look- ing to the history of human development through the ages, and from what point it started; estimating the value of beliefs; contrasting the faiths of to-day with the faiths of the far distant past; reflecting how different probably will be the faiths of the most distant future to which imagination can reach; and considering with the preacher the uncertain end of all the labour wherewith man labours under the sun;—is not likely to be strongly moved to destroy vigorously what seems error, or strongly urged to propagate zealously what seems truth, is likely rather, like Pilate, not jestingly, but in a cold spirit of philosophy, to ask, " What is truth ?" and amidst the turmoil of hot-headed partizans to sit, like Gallio, caring for none of these things. A nar- rowness and intensity of conviction, something of the same sort as the faith of a monomaniac in his particular revelation, and a fanatical zeal of action are THE BORDERLAND. 53 necessary to constitute the reformer. And in very truth it will be found that many of the great re- forms of thought and action have been initiated by persons either sprung from insane families, or some of whom might themselves have been thought in- sane. They present what in our ignorance we are constrained to call accidental variations of mental structure and function, which may, according to circumstances, either perish or initiate new lines of evolution. They have had the necessary zeal, and they have had also the impulse of originality, which is a sort of inspiration, for it cannot be acquired by reflection ; whence probably has arisen the supersti- tious notion, which has prevailed in certain coun- tries, that the insane were divinely inspired. They were cracked, but, as it has been remarked, the crack let in light. It was because in olden times madness was identified with the prophetical mania, and believed to be of supernatural origin, that the belief in the inspiration of the insane was entertained. This was the case among eastern nations, and even among the ancient Greeks madness, like epilepsy, was ac- counted a sacred disease. Hence the word mania was used to mean both madness and the prophetic spirit: " the greatest blessings we have spring from madness, when granted by the Divine bounty," Plato represents Socrates as saying. "For the prophetess at Delphi and the priestesses at Dodona have, when mad, done many and noble services for Greece, both privately and publicly; but in their 5 54 RESPONSIBILITY IN MENTAL DISEASE. sober senses little or nothing." It was as consider- ing it noble when it happens by Divine decree, that they gave it this name ; but the men of the present day, by ignorantly inserting the letter t, have called it the prophetic art.* Thus madness is identified with Divine inspiration, and the madman in this sense "is found fault with by the multitude as out of his senses; but it escapes the notice of the multi- tude that he is inspired." He is in fact in a higher and more exalted state of mind than that of a per- son in his sober senses, the result being not an in- creased power of calm and sustained thought, but brilliant flashes of wonderful insight. At the same time Plato distinguishes from this higher sort of mania the madness which proceeded from evil states of the body and the mind—the madness of folly, ignorance and insanity. There was the mania or madness belonging to the prophetic spirit, and there was the mania or madness of disease, running at times so close to one another as not to be distin- guishable. The prophets of the Old Testament, speaking as they probably did, in an impassioned manner, and * Mavla. madness—/xaviicf), the mad art—navriK-fi, the prophetic art. On this subject I may refer to the Rev. Augustus Clissold's work on " The Prophetic Spirit in its relation to Wisdom and Madness," from which I have taken these quotations. Mr. Clis- sold points out what he considers to be the inconsistency of those who accept the divine origin of the visions of the prophets of the Old Testament, and at the same time reject Swedenborg's visions and repudiate his prophetic claims. THE BORDERLAND. 55 with vehement gesticulation, as though possessed by a spirit which they could not resist, were looked upon as raving madmen. " Wherefore came this mad fellow unto thee ?" is asked of Jehu. And Shemaiah writes a letter declaring that the prophet Jeremiah is mad, and ought to be put in prison— (Jeremiah xxix., 26; Isaiah lix., 15). Then, as sometimes now, it was true : " Yea truth faileth; and he that departeth from evil is accounted mad." Of Christ himself it was afterwards said—" He is be- side himself." " He hath a devil and is mad,—why hear ye him ?" To Paul Festus exclaimed—" Paul, thou art beside thyself; much learning doth make thee mad." It is plain then that there has always been something in common recognised between the mental state of the inspired genius or prophet, and the mental state of the madman, whence it has come to pass that the terms mania and alienation of mind have been used to designate both states. There was an alienation of mind which was the result of divine inspiration, in which the mind was in an exalted state, and there was an alienation of mind which was the result of disease—a mania, which was divine inspiration, and a mania which was properly mad- ness or possession by an evil spirit. Possessed by a good spirit, the individual was a prophet; possessed by an evil spirit, he was a madman. Nor was it always easy to distinguish one state from the other, some of the prophets of the Old Testament, for example, presenting symptoms which can hardly be interpreted as other than the effects of madness; 56 RESPONSIBILITY IN MENTAL DISEASE. certainly, if they were not mad, they imitated very closely some of its most striking features.* Some may, perhaps, think it outrageous and ab- surd to suppose that any good or great event could proceed from a source contaminated by delusion or insanity; but not to take other illustrations, let any one who is inclined to be of that opinion consider the rise and progress of Mahometanism. There can * Jeremiah, under the influence of the prophetic spirit, pro- cures a linen girdle and puts it round his loins. He then takes a long journey to the Euphrates to hide it there in the hole of a rock, returns, and again, after many days, takes another long journey to the same place to take the girdle again out of the hole, when he finds it had begun to get rotten, and to be good for nothing. Ezekiel takes a tile, and portrays upon it the city of Jerusalem ; then he lays siege to this city on the tile, builds a fort against it, and casts a mount against it, and sets a camp against it, and battering rams against it round about it; then he takes an iron pan, and sets it for a wall of iron between himself and the city, and lays siege to the pan, as he had done to the tile ; and for a long time lies upon his left side before the tile, and then upon his right; he eats from time to time barley cakes which he had baked with cow's dung. The first command had been, " Thou shalt bake it with dung that cometh out of man;" but, in consequence of his protest, it was said, " Lo, I have given thee cow's dung for man's dung, and thou shalt pre- pare thy bread therewith." On another occasion he removes his household goods in the twilight by digging a hole through the wall of his house with his own hand, and carrying away some of his furniture on his own shoulders in the sight of some of the Jews, who came to see the strange things he was doing. Isaiah loosed the sackcloth from his loins, put off his shoes from off his feet, stripped himself naked, and for a time walked naked and barefoot, under the influence of the prophetic spirit. Hosea declared that he was commanded to take a wife of whore- dom ; and accordingly did so. THE BORDERLAND. 57 be little, if any, doubt in the minds of those who do not subscribe to that faith, that an epileptic seizure was the occasion of Mahomet's first vision and reve- lation, and that, deceived or deceiving, he made ad- vantage of his distemper to beget himself the repu- tation of a divine authority. The character of his visions was exactly of that kind which medical ex- perience shows to be natural to epilepsy; similar visions which are believed in as realities and truths by those who have them occurring not unf requently to epileptic patients confined in asylums. For my part I would as soon believe there was deception in the trance which converted Saul the persecutor into Paul the Apostle as believe that Mahomet at first doubted the reality of the events which he saw in his vision. But when we consider seriously what has come of these epileptic visions and ecstasies, we may well pause before venturing to declare what may or may not come of madness or allied condi- tions, and be cautious how we give credit to revela- tions which transcend the reach of our rational faculties. It will not be necessary for the Mahome- tan to reject the good which there may be in the teachings of Mahomet because he is constrained to reject the supernatural authority on which they were based. The observed resemblance between prophetic in- spiration and mania, which has been the occasion of the same name being applied to both, is a fact of no little interest in relation to what has been said of the insane temperament and of the family anteced- 58 RESPONSIBILITY IN MENTAL DISEASE. ents of some of those who have given birth to new ideas or have initiated great reforms in the world. The insane person is in a minority of one in his opinions, and so at first is the reformer, the differ- ence being that the reformer's belief is an advance upon the received system of thought and so in time gets acceptance, while the belief of the former be- ing opposed to the common sense of mankind gains not acceptance, but dies out with its possessor or with the few foolish persons whom it has perchance infected. But it has happened again and again in the world that opinions which seemed absurd to the common sense of mankind, and which were there- fore accounted madness, have turned out to be true. The novel mode of looking at things, which is char- acteristic of the insane temperament, may be an in- tuitive insight, a sort of inspiration, which laboured reflection could never attain unto; it is the very opposite in action to that bond of habit which en- thrals the mental life of the majority of mankind. The power of stepping out of the beaten track of thought, of bursting by a happy inspiration through the bonds of habit and originating a new line of reflection, is most rare, and should be welcomed in spite of its sometimes becoming extravagant or even degenerating into the vagaries of insanity. The individuals who manifest these impulses of develop- ment may not see their true relations, and may carry them to a ridiculous extreme, but they are still, per- haps, the unconscious organs of a new germ of thought, which shall plant itself and become largely THE BORDERLAND. 59 fruitful in the minds of others of a larger philo- sophic capacity, but not perhaps capable of the originating inspiration; for those who perceive and co-ordinate the tendencies of thought are commonly not those who originate them. There are antagonistic forces at work in the de- termination of the orbit of human thought as there are in the determination of the orbits of the planets —a centrifugal or revolutionary force giving the ex- pansive impulse of new ideas and a centripetal or conservative force working in the restraining influ- ence of habit; the resultant of their opposing actions being the determination of the path of the evolution of mind. Add to the eccentric impulse the ardent enthusiasm and passionate energy with which a be- lief is maintained and propagated, the self-sufficing faith which overcomes incredulity, gradually gain- ing disciples, and we have an explanation of the resemblance which has been noticed between the prophetic inspiration of genius and the mania of in- sanity. For the insane temperament may, according to the direction of its development, conduct its pos- sessor to madness, or make him the originator of some new thought or new thing in the world; the faith and labour with which he labours in the achievement of his aim actually saving him from the madness from which he might otherwise have suffered. Here as elsewhere we must have regard to the external circumstances as well as to the inter- nal fact in the determination of the result: we shall sometimes find one member of a family who has 60 RESPONSIBILITY IN MENTAL DISEASE, had an active career in a suitable track, go on through life without ever breaking down into men- tal derangement, while another whose circumstances have not been favourable becomes hopelessly insane. Those who devote themselves specially to the study and treatment of insanity are sometimes charged, not always unjustly, with the disposition to confound eccentricity with insanity, and to detect disease where persons not so biassed fail to perceive anything abnormal. Eccentricity is certainly not always insanity, but there can be no question that it is often the outcome of insane temperament, and may approach very near to or actually pass into in- sanity. Without making too much of peculiarities of thought, feeling, and conduct, that may be con- sistent with perfect sanity, there are facts to be borne in mind if the true interpretation of them is sought. In the first place, it will be observed that in families some members of which have displayed decided insanity, other members have been eccen- tric ; secondly, eccentricity, after lasting for a time as such, has culminated in insanity ; thirdly, mono- maniacs who are known to be insane on certain sub- jects are often eccentric in their wdiole conduct; and, lastly, persons, who have been decidedly insane, having laboured under one of the recognised forms of mental derangement, often remain eccentric dur- ing life after their reputed recovery. While we acknowledge that the insane tempera- ment is not always an unmixed evil, but may some- times issue in a favourable development, we must THE BORDERLAND. 61 concede at the same time that it is always more or less a danger to the individual. When subjected to any great stress, arising from outward circumstances or from bodily disorder, he is more likely to break down in health of mind than a soundly constituted and stable organisation. Such physiological changes as the advent of puberty with the bodily and men- tal commotion which accompanies it, the occurrence of pregnancy, the climacteric change, are sometimes fraught with danger to the mental stability, while the disappointments and calamities of life will obvi- ously act with greater effect upon an unstable men- tal organisation; all these causes of disturbance meeting with a powerful co-operating cause in the constitutional predisposition. Moreover, the diffi- culties of education are greater in such a case. The natural impulses of the temperament manifest them- selves early in life, requiring an attention and dis- cipline which few persons are qualified to give, and which are not suitably applied in the routine of an ordinary education; the consequence being that during the important period of growth, when much may be done by proper training to determine the formation of character, the natural bias gains strength through indifference and inattention, or by a med- dlesome interference is too violently checked. In the foregoing remarks I have spoken gener- ally of the insane temperament, but there are really varieties of it, a description of which would proper- ly find its place in a treatise on insanity. All our present concern is to recognise distinctly that there 62 RESPONSIBILITY IN MENTAL DISEASE. is such a temperament, which, though by no means abolishing an individual's responsibility, must be taken into account when deeds of violence are done which seem to mark the outbreak of actual mental derangement. Unwarrantable as it may appear, to assume a crime to be evidence of insanity, when there have not been any previous symptoms to in- dicate disease, it is still possible that the crime may mark the period when an insane tendency has passed into actual insanity—when the weak organ has given way under the strain put upon it. There is one occasional consequence of descent from an insane stock, however, which is of special interest in our present inquiry—namely, an entire absence of the moral sense. To those who take the metaphysical view of mind, it will no doubt seem improbable that absence of moral sense should ever be a congenital fault of mental organisation, but if we are to put any trust in observation, we must ac- knowledge such a defect to occur sometimes in con- sequence of parental insanity. It may be witnessed, even in young children, who, long before they have known what vice meant, have evinced an entire ab- sence of moral feeling with the active display of all sorts of immoral tendencies—a genuine moral im- becility or insanity. As there are persons who can- not distinguish certain colours, having what is called colour-blindness, and others who, having no ear for music, cannot distinguish one tune from another, so there are some few who are congenitally deprived of moral sense. Associated with this defect there THE BORDERLAND. 63 is frequently more or less intellectual deficiency, but not always ; it sometimes happens there is a remarkably acute intellect with no trace of moral feeling. Here, then, we are brought back to the connec- tion between crime and insanity. A person who has no moral sense is naturally well fitted to become a criminal, and if his intellect is not strong enough to convince him that crime will not in the end succeed, and that it is, therefore, on the lowest grounds a folly, he is very likely to become one. As I have pointed out in the first chapter, criminals often do come of families in which insanity or some other neurosis exists, and instances are met with in which one member of a family becomes insane, and another reckless, dissipated, depraved, or perhaps even crim- inal. Several striking instances of the kind are re- lated by Morel,* who has traced and set forth in an instructive manner the course of human degeneracy in the production of morbid varieties of the human kind. Dr. Prichard mentions the case of a family, several members of which were afflicted with in- sanity, and were confined in asylums; they resem- bled each other ; and the disease showed itself when they attained nearly the same period of life. A younger brother had a different organisation of body from the rest, and seemed likely to escape. There was only one other instance of immunity from the disease in the family—one, as he remarks, of still * Traite des Maladies Men tales. 64 RESPONSIBILITY IN MENTAL DISEASE. greater calamity. It was that of a brother who had never been, nor was thought to be, actually insane, but who was through life a reckless and depraved reprobate, and occasioned the greatest distress and vexation to his friends. If the secrets of their na- tures were laid open, how many perverse and wrong- headed persons, whose lives have been a calamity to themselves and others, how many of the depraved characters in history, whose careers have been a cruel chastisement to mankind, would be found to have owed their fates to some morbid predispo- sition ! Let it be noted, then, that the independent in- quiries of observers in different departments of nature bring us to the same conclusion with re- gard to the essential dependence of moral sense upon organisation. In the first chapter it was pointed out that the investigations of those who have made criminals their study have resulted in a conviction of a frequent defect or absence of moral sense, in consequence of defective organisation ; and it has now been shown that the observations of those who have made insanity their study, have resulted in a conviction that the absence of moral sense is an occasional result of descent from an insane family. Pursuing two distinct paths of inquiry we have reached the same conclusion. Moral feeling can- not, therefore, be considered satisfactorily from a mental stand-point alone, as if it had no connection with physical structure; it is a function of organi- sation, and is as essentially dependent upon the in- THE BORDERLAND. 65 tegrity of that part of the nervous system which ministers to its manifestations as is any other dis- play of mental function. Its sanction is given to such actions as are conducive to the well-being and the progress of the race, and its prohibitions fall upon such actions as would, if freely indulged in, lead to the degeneration, if not extinction, of man- kind ; in other words, when it is in healthy func- tional action, its function, like that of any other part of the body, is conducive to the well-being of the organism; when it is not exercised it decays, and so leads to individual degeneration, and, through individuals, to degeneracy of race. The medical psychologist must hold that the best of the argument concerning the origin of the moral sense is with those who uphold its acquired nature. That the sentiments of common interest in the primitive family and tribe, and the habitual rep- robation of certain acts by individuals as injurious to the family or tribe, should finally generate a sen- timent of right and wrong in regard to such acts, and that such sentiment should in the course of generations be transmitted by hereditary action as a more or less marked instinctive feeling, is in entire accordance with what we know of the results of education and of hereditary action. Time was, we know, when men wandered about the country in families or tribes. In order that they might rise from this nomadic state to a national existence, the acquisition and development of a moral sense must clearly have been essential conditions—not, how- 6Q RESPONSIBILITY IN MENTAL DISEASE. ever, as preformed agents, but as concomitant effects, of evolution.* This development is still going slowly on; but the proof how little moral sense itself instigates progress is seen in the absence of it between nations. Men have risen to a national ex- istence, but they have not yet risen to an interna- tional existence. With moral principles that have not changed within historical times, nations still laud patriotism, which is actually a mark of moral incompleteness, as the highest virtue; and states- men sometimes think it a fine thing to sneer at cos- mopolitanism. But it cannot be doubted that the time will come, though it may be yet afar off, when nations will know and feel their interests to be one, when moral feeling shall be developed between them, and when they shall not learn war any more; it will come as a step in evolution and as a condition of universal brotherhood, not otherwise than as, coming between tribes, it bound them into nations, and made patriotism the high virtue which it is be- lieved to be.f * " And if we could imagine the human race to live back again to its earliest infancy—to go backward through all the scenes and experiences through which it has gone forward to its present height—and to give back from its mind and charac- ter at each time and circumstance, as it passed it, exactly that which it gained when it was there before—should we not find the fragments and exuvias of the moral sense lying here and there along the retrograde path, and a condition at the begin- ning, which, whether simian or human, was bare of all true moral feeling V—Body and Mind, p. 58. f The patriotic feeling which makes the individual sacrifice THE BORDERLAND. 67 If other arguments were needed in support of the opinion that conscience is a function of organiza- tion—the highest and most delicate function of the highest and most complete development thereof— they might be drawn from observation of conditions of moral degeneracy. Let it be noted how it is per- verted or destroyed sometimes by disease or injury of brain. The last acquired faculty in the progress of human evolution, it is the first to suffer when disease invades the mental organization. One of the first symptoms of insanity—one which declares itself before there is any intellectual derangement, before the person's friends suspect even that he is becoming insane—is a deadening or complete per- version of the moral sense. In extreme cases it is observed that the modest man becomes pre- sumptuous and exacting, the chaste man lewd and obscene, the honest man a thief, and the truthful man an unblushing liar. Short of this, however, there is an observable impairment of the finer moral feelings—a something different, which the nearest friends do not fail to feel, although they can- not always describe it. Now, these signs of moral perversion are really the first symptoms of a men- tal derangement which may, in its further course, go through all degrees of intellectual disorder and himself for the good of his country is, of course, a high moral feeling; but the word "patriotism" is often used, or misused, to denote that national feeling which places the interests of a country before those of humanity, and which inspires such an expression as " Our country against the world." 68 RESPONSIBILITY IN MENTAL DISEASE. end in destruction of mind, with visible destruc- tion of the nerve-cells which minister to mind. Is the end, then, dependent on organization, or rather disorganization, and is the beginning not? This course of degeneracy is but a summary in the indi- vidual of what may be traced through generations ; and in both cases we are constrained to believe that the moral changes are as closely dependent upon physical causes as are the intellectual changes which accompany or follow them. If it be not so, we may bid farewell to all investigation of mental function by a scientific method. Note, again, the effect which a severe attack of insanity sometimes produces upon the moral nature of the individual. The person entirely recovers his reason; his intellectual faculties are as acute as ever, but his moral character is changed; he is no longer the moral man that he was ; the shock has destroyed the finest part of his mental organi- zation. Henceforth his life may be as different from his former life as, in an opposite direction, was the life of Saul of Tarsus from the life of Paul the Apostle to the Gentiles. An attack of epilepsy has produced the same effect, effacing the moral sense as it effaces the memory sometimes; and one of the most striking phenomena observed in asylums is the extreme change in moral charac- ter in the epileptic which precedes and heralds the approach of his fits. A fever or an injury to the head has in like manner transformed the moral character. Many instances from different quarters THE BORDERLAND. 69 might be brought forward in illustration of such physical effect upon moral being, but one men- tioned by Dr. Prichard, which lies to hand, may suffice. In a large and well-regulated family all the members save one boy were of quiet and sober habits, of excellent disposition, and regular and industrious. This boy met with a severe ac- cident, which injured his head. As he grew up he was quite different from the other children ; he was utterly unmanageable, dissipated, wild, addicted to all kinds of excesses,—was on the verge of mad- ness, though not intellectually deranged. Dr. Wigan puts the matter in a way that may seem more extravagant than it really is when he says :— " I firmly believe that I have more than once changed the moral character of a boy by leeches to the in- side of the nose." In bringing this chapter to an end, I shall note down three definite propositions, and make one general reflection, which may fitly be drawn from a consideration of its contents. The propositions are these:—That there is an insane temperament which, without being itself disease, may easily and abruptly break down into actual disease under a strain from without or from within; that moral feeling, like every other feeling, is a function of organization; that an absence of moral sense is an occasional result of descent from an insane family. The reflection which occurs is that, before entering upon the consideration of the degree and manner in which responsibility is modified by disease, it is 70 RESPONSIBILITY IN MENTAL DISEASE. necessary to realize the of these propositions—: victions the modified i ological study of mind been hitherto questions ology. full physiological meaning ;o take home to our con- elations in which a physi- places questions that have of pure psychology or the- CHAPTEK III. DIFFERENT FORMS OF MENTAL DERANGEMENT. Idiocy and imbecility—Kleptomania, pyromania, &c, often mark imbecility—Intellectual and affective insanity—Gen- eral and partial mania—Monomania and melancholia—De- mentia—General paralysis of the insane—Objection to the received system of classification according to certain promi- nent 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 classification—The path of future medical inquiry—The physician's duty to declare the truth, however unpopular it may be. The observer who proceeds to examine the dif- ferent kinds of mental incapacity under which men labour, perceives at the outset that he must distin- guish cases of absence or weakness of mind from cases in which there is derangement of mind: the former being instances of Idiocy or Imbecility, the latter of Insanity proper. Idiocy is a defect of mind which is either con- genital, or due to causes operating during the first few years of life, before there has been a develop- ment of the mental faculties, and may exist in different degrees; the person afflicted with it may have the power of articulate speech, and manifest a 71 72 RESPONSIBILITY IN MENTAL DISEASE. limited degree of intelligence, or he may be utterly destitute of any semblance of intelligence and of the power of speech, being little more than a mere vegetating organism. Imbecility is simply weak- ness of mind owing to defective mental develop- ment, and may be of every degree of deficiency, moral and intellectual; on the one hand, passing by imperceptible gradations into idiocy, and, on the other hand, passing insensibly into ordinary intelli- gence. There are some imbeciles in whom a gen- eral deficiency of intelligence is accompanied by a singular development of it in a special direction; they manifest, for instance, a surprising memory for details, such as dates, names, numbers, the exact particulars of distant events, which they recall and recount with the greatest ease and accuracy, or dis- play certain remarkable mechanical aptitudes, or exhibit a degree of cunning which might seem in- consistent with their general mental feebleness. To establish the existence of imbecility in any case it must be shown that there is a defect of understanding, not merely from a want of devel- opment of the mental faculties in consequence of a deficient education, but a defect of understanding by reason of some natural incapacity which no education will overcome—a mental privation. It is clear, however, that ignorance which is the re- sult of utter neglect, though neither doctors nor lawyers would regard it as imbecility, might justly, on grounds of humanity, be held to lessen respon- sibility. DIFFERENT FORMS OF MENTAL DERANGEMENT. 73 Obviously it must sometimes be a very difficult matter to decide whether there is actual imbecility or not, while the question of the degree of the indi- vidual's responsibility will be a more difficult one still—may, in fact, be practically insoluble. There can be no dispute with regard to the irresponsibility of idiots; deprived of understanding by a fate against which they cannot contend, it would be ab- surd to talk of responsibilities and obligations in connection with them. But it is not so with imbe- ciles : some of them fail as clearly as idiots to reach the standard of responsibility, but others undoubt- edly have a knowledge of right and wrong, and some power to do the right and forbear the wrong. In face of their natural defect, however, it would not be just to assign to them a full measure of respon- sibility; so that we are driven to recognise theo- retically an entire absence of responsibility and a modified responsibility. In like manner some are capable of managing their affairs, others are not, while of others it is hard to say whether they are or are not. No special rules can be formulated for deter- mining the question either of responsibility or ca- pacity in conditions of imbecility; each case must be considered on its merits, the entire conduct of the individual through life being taken into ac- count, in order to jutlge how far it betokens mental deficiency. It is a matter of observation that im- pulses to theft, incendiarism, and violence, are not uncommon in these cases where the intelligence is 74 RESPONSIBILITY IN MENTAL DISEASE. feeble and the passions are strong; and many crimes, such as arson, rape, theft, and homicide it- self sometimes, are perpetrated by actual imbeciles : they are beings who have reached a lower stage of race-degeneracy than those criminals who, as pointed out in a former chapter, approach the im- becile type. On proceeding to examine the manifold varieties of insanity, it is found that they may be arranged in two great divisions according to the presence or ab- sence of palpable intellectual derangement. The first division will be formed of all those cases in which there is insanity of thought or insanity with de- lusion, and may be described as Intellectual or Idea- tional Insanity / the second division will consist of all those cases in which, without delusion or inco- herence, there is insanity of feeling and action, and may be properly described as Affective Insanity. Here, at the outset, medical experience comes into collision with legal tradition and popular preju- dice. The common opinion is that a person who is insane must discover his disease by delusions, or raving, or great extravagance of conduct, and that, failing some marked exhibition of the kind, he can- not be mad ; in fact, that madness, if it exist, is so palpable a thing that no one can fail to recognise it. Lawyers, whose knowledge of insanity is for the most part not greater than that of the vulgar, share this opinion ; accordingly, when the physician testi- fies to the existence of less marked forms of dis- ease, in which the indications are of a more sub- DIFFERENT FORMS OF MENTAL DERANGEMENT. 75 tile and obscure character, they are apt to think that he is propounding ingenious and fanciful theories, in order to exhibit his own cleverness, or that he has been so biassed by the nature of his studies that he will detect insanity wherever he sets earnestly to work to look for it. But facts re- main and assert themselves when ridicule has spent itself in scorn of medical theories. There can be no doubt that there do exist cases of insanity in which the intellectual derangement is scarcely, if at all, apparent; and, furthermore, that some of the most dangerous forms of the disease are of this kind— most dangerous, indeed, because the insanity dis- plays itself not in thought but in acts. It is neces- sary, therefore, to make a class of these cases, even though it may not please those who have not had the opportunity, or have not been at the pains, to ac- quaint themselves with the facts. On examining the cases of intellectual insanity or mania (the term mania being often used in its general sense as synonymous with insanity), it is seen that there are some in which the derangement of thought is general, the person exhibiting various delusions or more or less incoherence, and that there are others in which the derangement of thought ap- pears to be limited to one subject, or to a certain order of ideas, the understanding being clear in other matters. The former are included under the class of what is called General Mania, which may be acute or chronic, the latter under the class of Partial Mania, which is always of a chronic na- 76 RESPONSIBILITY IN MENTAL DISEASE. < ture. It is seldom that any question of responsibil- ity arises with regard to general mania, the mental derangement being unequivocal, although it may be remarked by the way that if the legal criterion of responsibility, which is a possession of knowledge of right and wrong in reference to the particular act, were strictly enforced in every case, it would some- times entail the condemnation and punishment of persons labouring under general mania, who, in the wantonness of their fury, do acts of violence which they know well they ought not to do, but which at the same time they cannot help doing. The existence of a so-called partial mania is readily admitted : there is neither popular nor legal unwillingness to concede that a man may be insane upon one point and sane in all other respects, al- though, rightly considered, such a doctrine is more remarkable than that a man should evince insanity of feeling and conduct without delusion ; indeed, there is a tendency rather to overrate the frequency of occurrence of such a state, and to give it a more rigid definition than is conformable with nature. The collision between medical experience and legal dogma takes place here in reference to the responsi- bility of a person so suffering, in the event of his committing a crime which is not manifestly the off- spring of his delusion; the lawyers asserting, and the doctors denying, that he ought to be punished exactly as if he were of entirely sound mind. It is usual to make a subdivision of partial insan- ity into monomania and melancholia, according to DIFFERENT FORMS OF MENTAL DERANGEMENT. 77 the character of the feeling which accompanies the delusion of thought: when the person is elated, con- fident, self-complacent, and has deranged ideas in conformity with these feelings, he is said to labour under monomania • when he is depressed, wretched, distrustful, and has corresponding unsound ideas, he is said to labour under melancholia. Some authors, however, raise melancholia into a special class, using monomania and partial mania as synonymous terms, notwithstanding that some cases of melancholia really afford the most striking examples of partial insan- ity ; this they do because cases occur in which there are many fearful apprehensions and delusions with corresponding distress—because, in fact, there is general intellectual derangement with melancholic depression. All cases of melancholia cannot prop- erly, therefore, be described as cases of partial in- sanity, some being really cases of acute general de- rangement, which again run so near to, or so run into, acute mania that they cannot always be distin- guished from it. The term monomania, if used of melancholia at all, should be applied to the chronic form of the disease only—to that which Esquirol proposed to distinguish as Vypemania. The uncer- tainty of these divisions, which is thus made appar- ent, attests the artificial and unsatisfactory nature of the received classification, which holds its ground only because a better one has not yet been pro- pounded, or, if propounded, has not gained accept- ance. When any of the above-mentioned forms of in- 78 RESPONSIBILITY IN MENTAL DISEASE. sanity has lasted for some time, without amendment taking place, the mind is often weakened, and the person, passing through degrees of craziness, falls finally into a condition of what is called dementia. It is the destruction of mind by disease, and may of course be more or less general and complete; in the worst cases demented patients have as little intelli- gence as the complete idiot, from whom, however, they differ in having lost what he never possessed. There is one striking form of insanity in which mental symptoms of a tolerably uniform character are accompanied by symptoms of gradually increas- ing paralysis of the muscular system, and which runs a definite course to a fatal termination; it is usual, therefore, to make of it a special class under the name of General Paralysis of the Insane. Here, it will be observed, there is a departure from the prin- ciple of classifying insanity according to its promi- nent mental features; the bodily symptoms which accompany the mental derangement being taken into account, and made the basis of the name. With this exception, however, the received clas- sification is founded on the recognition of a few of the most prominent mental symptoms only—is purely psychological. It amounts simply to this: when a person is excited, and raves more or less in- coherently, he has acute mania; when, after sub- siding into a more quiet state, he continues to have delusions and to be incoherent, he has chronic mania ; when he exhibits insane delusions on one subject or in regard to certain trains of thought, and DIFFERENT FORMS OF MENTAL DERANGEMENT. 79 talks sensibly in other respects, he is said to have monomania; wdien he is gloomy, wretched, and fancies himself ruined or damned, he has melan- cholia / and when his memory is impaired, his feel- ings quenched, his intelligence enfeebled or extinct, he is said to be suffering from dementia. Much dissatisfaction has been felt with this classification, and many fruitless attempts have been made to supersede it by a better one. It is ex- tremely vague, and obviously teaches us very little concerning the disease ; it is in fact a rough classifi- cation of certain marked symptoms, not an exact classification of the different varieties of disease which are included under the general term insanity; we learn nothing from it concerning the cause of the particular form of disease, its course and dura- tion, its probable termination, its most suitable treatment. Moreover, it has done not a little mis- chief by confining attention to a few general mental features, and diverting observation from the various physical causes and symptoms of the disease; it has strengthened the notion that insanity is a disease of mind, without at the same time bringing into promi- nence the fact that it is a disease of body also. No wonder it has been said that any one of good com- mon sense is as competent as a medical man to de- termine whether a person is insane or not. This assertion would not be disputed if we could only guarantee the application of true common sense, which proceeds from experience and knowledge, and in any department of scientific inquiry is the 80 RESPONSIBILITY IN MENTAL DISEASE. common sense of those who have these qualifica- tions ; the so-called common sense of any one not so enlightened is very apt to be common prejudice springing from ignorance; and assuredly it would argue in such a one a very uncommon sense, if he was, without special experience, as competent as those who had laboured hard to inform themselves by a patient study of the disease in all its stages. Is it not truly strange that common sense should ever have been declared to be the measure of that the essence of which is that it is not sense—that it is utterly opposed to all the experience of sanity ? An example will serve best to show how neces- sary to the formation of a right conclusion is obser- vation informed by experience.* A man who has been hitherto temperate in all his habits, prudent and industrious in business, and exemplary in the relations of life, undergoes a great change of char- acter, gives way to dissipation of all sorts, launches into reckless speculations in business, and becomes indifferent to his wife, his family, the obligations of his position; his surprised friends see only the effects of vice, and grieve over his sad fall from virtue; after a time they hear that he is in the police court accused of assault or of stealing money or jewelry, and are not greatly astonished that his vices have brought him to such a pass. Examined by a competent physician, he is discovered to have a slight peculiarity of articulation and perhaps an in- equality of size of the pupils, symptoms which, in conjunction with the previous history, enable the DIFFERENT FORMS OF MENTAL DERANGEMENT. 81 physician to say with positive certainty that he is struck with a disease which, sapping by degrees his intellect and strength, will within no long time de- stroy his mental and bodily powers, and finally his life. Our knowledge is so exact that we can do what is the best test of a science—predict with certainty what will happen. The dissipation, the speculation, and the theft itself were, as they often are, the first symptoms of general paralysis of the insane. Plainly, common sense without special ex- perience could have small chance of coming to a right conclusion in such a case. The example will furthermore serve to show of what little service a classification by mental symptoms only is, and what little information we get when we are obliged to be content with such a classification; for in the early stages of the disease it would be necessary to de- scribe them as those of affective or moral insanity, at a later stage as those of intellectual insanity, and finally as those of dementia. Thus one patient might, in the course of a short time, run through all the classes of symptoms while suffering from one and the same disease. So plain is this, and so char- acteristic are the mental and bodily features of gen- eral paralysis, that all writers on insanity are agreed in making it an exception to the general rule of classification; they constitute it a class by itself, thus giving the strongest practical condemnation to a purely psychological classification. The example which has been used to exhibit the defect may be used also to indicate the remedy. 82 RESPONSIBILITY IN MENTAL DISEASE. We have only to do with other forms of insanity as we have done with general paralysis—to study care- fully their natural histories, and so to endeavour to arrive at a natural classification of them. By exact observation of the cause, the bodily and mental symptoms, and the course of the disease in each case, and by an accumulation of such observations, it is believed that we shall in time be able to form natural groups or families, each having certain char- acteristic features, a knowledge of which will at once teach us something definite concerning the causation, course, and probable termination of a particular case belonging to the group. Our aim should be to apply the strict rules of inductive ob- servation and generalization to the study of insanity from its earliest beginnings to its latest stages—to inquire closely into the antecedent conditions of the disease in each case, to observe accurately all the facts, physical and mental, that are presented in its course, to make experiments, as it were, on the pa- tient, by using means to elicit his individual pecul- iarities of mind, as we use means to detect his bodily ailments, and so to obtain a complete and accurate history of the disease. Having accumulated a num- ber of such observations, the arrangement of them in groups, or the generalization of them into natural types, will follow, so that when a particular case presents itself in practice it will be possible, by re- ferring it to its natural order, to bring definite in- formation to bear upon it, instead of, as under the present system of denoting by a vague name a DIFFERENT FORMS OF MENTAL DERANGEMENT. 83 variety of diseases, some of which have nothing more in common than the particular symptom from which the name has been derived, gaining little or no definite knowledge of it. It is evident that the farther medicine advances on this path of inductive inquiry, the less it will be exposed to the criticism of lawyers and others who have no practical knowledge of the disease. It will be impossible to declare, as an English Lord Chan- cellor ignorantly declared not long ago, that in- sanity is properly a subject of moral inquiry, and to condemn, as he ventured foolishly to do, " the evil habit which had grown up of assuming that it was a physical disease;" it will become more and more evident that the decision of its nature must be guided by the knowledge of those who have made it their study; and every one will see the absurdity of the pretension of lawyers to make a medical diag- nosis of insanity without medical aid, as every one would now see the absurdity of their pretension to make a diagnosis of fever or of small-pox. Not that the cases are exactly similar : for while medical men are making a diagnosis of insanity in a doubtful case where it is alleged in explanation of crime, it must be remembered that the law is also concerned to make a diagnosis—the diagnosis of crime; and the symptoms from which both lawyers and medical men must come to a conclusion are many of them the same. Unfortunately while the lawyer can see and appreciate the symptoms which indicate crime, he cannot appreciate the symptoms which mark dis- 84 RESPONSIBILITY IN MENTAL DISEASE. ease; these he overlooks or ignores, for they have no meaning to him; and he is apt to think that the physician who does perceive them and recognise their serious meaning, is simply making crime evi- dence of insanity. The theft in the early stages of general paralysis is a sufficiently palpable fact; who but a physician familiar with the disease can recog- nise the inequality of pupils and the peculiarity of articulation which mark the beginning of incurable brain-disease, and give the true interpretation of the theft ? Insanity being a disease which cannot exist apart from disorder of bodily organs and functions, the diagnosis of it must belong to the physician; for he alone is competent to investigate and appre- ciate these disorders. Those who would take from him the diagnosis might as well claim to take the treatment of the disease. The late M. Morel, who was the distinguished physician of the asylum of St. Yon, near Rouen, some years ago propounded a new system of clas- sifying insanity, which, although not available for practical purposes and easily shown to be defective as a theoretical system, had the merit of expressing the tendencies of modern inquiries in a systematic form. His aim was the classification of mental dis- orders in relation to their causes, and he arranged all forms of them in six principal groups, each group having its different subdivisions into classes or varieties. The mention of these groups will serve fitly to show how essentially a bodily disease insanity is, and how little real knowledge of its DIFFERENT FORMS OF MENTAL DERANGEMENT. 85 causation and nature in any case can be obtained except by way of medical observation and inference. The first group he designated Hereditary Insan- ity. All cases belonging to it have, he affirmed, special characters by which they may be recognised; the outbreak of the disease may be determined by ordinary causes, but, once it has been developed, there are special features in its form, its course, and its termination which to a skilled observer clearly denote its origin. The second group comprises all cases of insanity in which the disease has been caused by the habitual use of intoxicating and nar- cotic substances, such as alcohol, opium, haschisch; or by poisonous substances, such as phosphorus, lead, and mercury; or by exposure to the baneful influence of marsh miasmata. The peculiar disor- ders of the physical and mental functions observed in all the varieties of this group, though presenting special differences necessitating subdivisions, have so much in common, are in fact said to be so far characteristic, as to warrant the formation of the group to which he gave the name of Toxic Insan- ity. The third great group consists of insanity oc- casioned by the transformation of other neuroses, and includes hysterical, epileptic, and hypochondri- acal insanity. The hysteria, the epilepsy, and the hypochondria exercise a special influence upon the nature of the ideas and acts of those who suffer from them; the kind of derangement in each case reflecting the fundamental character of the neurosis of which it is a transformation, although each kind 7 86 RESPONSIBILITY IN MENTAL DISEASE. has at the same time characters that are common to it and the other divisions of the group. His fourth group comprised all cases in which the insanity is owing to idiopathic disease of the brain. Chief among these is general paralysis of the insane, con- stituting the principal variety; another variety be- ing formed of those cases in which there is gradual enfeeblement or abolition of the mental faculties in consequence of chronic disease of the brain or its membranes. The fifth group he designated Sym- pathetic Insanity, and it included all the cases in which the primary seat of disease is not in the brain, but in some other organ of the body, the brain being secondarily and sympathetically affected. The sixth and last group was not founded on any relation of the disease to its cause, the principle of the classification being departed from, but was made for the sake of convenience; in it were included all cases of dementia—the terminal stage of mental de- generation. I shall not enter into an exposition of the faults of this scheme of classification which has been pro- pounded by Morel; let it suffice here to point out that it has the merit of bringing into just promi- nence the physical causation of insanity. Without doubt the disease may be caused in every one of the ways described by Morel; and without doubt, when it is so caused, there are usually bodily symptoms which are as essential a part of the disease as are the mental symptoms which chiefly attract the atten- tion. Instead then of seizing upon a prominent DIFFERENT FORMS OF MENTAL DERANGEMENT. 87 mental symptom, such as an impulse to suicide, homicide, theft, incendiarism, which may be met with in a particular case, and thereupon making such pathological entities as suicidal mania, homici- dal mania, kleptomania, and pyromania, which have no existence as distinct diseases, the aim of the in- quirer should be to observe carefully all the bodily and mental features, and to trace patiently in them the evolution of the cause. Given a case of insan- ity in which homicidal impulse is displayed he will observe with what other symptoms the impulse is associated, will thereupon refer the case to the natu- ral group to which it belongs, and set forth its rela- tions to its cause; so he will present an accurate picture of a real disease, instead of concealing in- adequate observation under a pretentious name, and offering the semblance of knowledge by the creation of what can be described only as a morbid meta- physical entity. To the late Dr. Skae of Morningside we are in- debted for another praiseworthy attempt to distrib- ute the varieties of mental derangement in natural groups having characteristic features. He proposed to classify insanity, not by its mental symptoms, but by the bodily states of which the mental disorders are the accompaniments ; in this way he propounded as many as thirty-five groups, each having a particular bodily condition and a special psychological charac- ter. This is not the place to describe and discuss these so-called natural orders, which have yet to establish their claim to acceptance; it will be suffi- 88 RESPONSIBILITY IN MENTAL DISEASE. cient to indicate briefly their character, in order to show on what physical paths scientific investigation of mental derangement is now proceeding. The first natural group is idiocy, including im- becility in all it various forms and degrees. In this group must be placed all cases of true moral idiocy and imbecility, many of which appear in the present classification as monomanias of various kinds—for example, cases of instinctive cruelty, destructiveness, and theft. Many kleptomaniacs have, as Dr. Skae justly remarked, had that tendency from their child- hood, and have been moral imbeciles. The second group is that of epileptic insanity, including the cases of insanity occurring in connection with epilepsy, some, if not all, of which certainly present special psychological features. Another group is the insan- ity of pubescence, the disease occurring about the pe- riod of pubescence and being apparently initiated by the changes in the circulation and nervous system which then take place. That these important changes do produce a great revolution in the mental and bodi- ly economy, and become sometimes causes of insan- ity, especially in those who have a predisposition to the disease, is beyond question, and that the mental symptoms are in some respects special, if not quite distinctive, may also be admitted. The insanity of pregnancy, puerperal insanity, and the insanity of lactation constitute again three distinct groups, a knowledge of the features of which should enable a skilled observer at once to place a particular case in its proper category. At the change of life in women DIFFERENT FORMS OF MENTAL DERANGEMENT. 89 an outbreak of mental disorder sometimes occurs, which, presenting special features, may be described as climacteric insanity. When insanity occurs in connection with phthisis, and especially when the diseases manifest themselves in the patient about the same time, the mental derangement exhibits peculiarities of features which are supposed to jus- tify the formation of a group of cases under the name of phthisical insanity. The insanity of old age, which may begin as mania or melancholia, but generally presents more or less marked features of dementia, constitutes the distinct natural group of senile insanity. Delirium tremens and its allied disease dipsomania constitute two more groups. These may serve as examples of the natural or- ders which Dr. Skae sketched out. All the cases which cannot be referred to any one of them he classes under the general name of idiopathic insan- ity, divisible into two varieties,—sthenic and asthe- nic, according to the strong or feeble condition of the bodily health. All of them, whether acute or chronic, whether sthenic or asthenic, whether the symptoms are those of excitement or depression, are to be referred to moral causes, such as loss of for- tune or relative, or severe mental shock or strain of some kind, and are all preceded by the same proxi- mate cause—want of sleep. From the names used in this classification to designate the different groups, it might naturally be looked upon as a classification based upon etiology —that is, upon the observed or imagined causation 90 RESPONSIBILITY IN MENTAL DISEASE. of the disease in each case. But this was not its author's intention ; his real aim having been to ap- prehend all the special features in the entire natural history of the disease—in its early symptoms, its variations, its course and termination, as well as its supposed cause, and so by bringing together similar cases to constitute a natural family or group of cases. The supposed cause or partial cause is used only as the most convenient designation for the group. The name is not of much moment so long as we are not led astray by it: the important ques- tion of course is whether there are really so many distinct groups having characteristic features, so many true natural orders, as are described, and this is a question which can only be answered after care- ful observation in a large field of experience. Whatever may be the result of future inquiries, it is certain that some of the proposed natural or- ders are of practical value, and that they are founded on a method which the experienced physician in- stinctively follows when he has to give an opinion with regard to a case of mental derangement. He does not ask himself whether it is a case of mania or melancholia, for he knows that he gets no real in- formation thereby, but he asks himself such ques- tions as whether it is connected with epilepsy, or phthisis, or childbirth, or is a case of general paraly- sis, and thereupon compares it with a similar case which has occurred in his practice. The more ex- periences of a like kind he has thus stored up in his memory, the sounder will his judgment be in a par- DIFFERENT FORMS OF MENTAL DERANGEMENT. 91 ticular case; the difference between a skilled physi- cian and one who has less skill in insanity, as in other departments of an inexact science like medi- cine, being in the number and variety of cases which he can thus call up from the stores of his ex- perience. He may not always be able to impart to others an exact account of the steps by which he has reached his conclusion, unconscious acquisition and instinctive decision preceding conscious method and deliberate judgment, but his opinion may still be sound. When he can say of one form of insanity, as he can of general paralysis, which in its early stages is not unf requently punished as crime, that it is a physical and mental disease which will run a definite course, present certain characteristic symp- toms, and end in a certain way, commonly within a certain time, he may fairly claim that some weight should be attached to his opinions in cases concerning which he is unable to speak with equal precision. Assuredly he may demand that, Lord Chancellors notwithstanding, insanity should be treated, not as a subject of moral inquiry, but as a disease to be in- vestigated by the same methods as other diseases. I have made these remarks on classification, not with the design of discussing here what would prop- erly belong to a treatise on insanity, but in order to point out the path of exact inquiry which is now be- ing pursued by those who are engaged in the study of the disease. They not only recognise that it is a bodily disease, but they are labouring with increas- ing success to discover the particular bodily de- 92 RESPONSIBILITY IN MENTAL DISEASE. rangements with which particular mental symptoms are associated. It is plain that as they advance upon this path they must arrive at results which are less and less within the apprehension of those who have not made the disease a study, and that they may expect to escape some of the criticism of which they now receive such abundant measure. They will occupy a position more like that of the chem- ical expert, who deals with matters which all per- sons acknowledge to lie beyond the range of un- taught apprehension. There are few who, without having had a special chemical training, would ven- ture to pronounce an opinion on the value of the chemical evidence given in a case of poisoning, but everybody thinks himself competent to say whether a man is mad or not; and as the com- mon opinion of an insane person is that he is either a raging maniac or that he has some outra- geous delusion, it is no wonder that judgments have sometimes been rash and censures unjust. Mean- while the physician, confident in the assurance that patient and careful observation of insanity, with the earnest desire to understand its nature, does fit him to express with authority the results of his experi- ence, must not shrink from pronouncing his opinion sincerely and fearlessly, however unpopular it may be. "A wretch foredoomed to insanity by mal- organization or hereditary defect, or driven mad by poverty, or by disappointment acting on a distem- pered brain, has no other friends in the world. . . . The same courage which causes the physician to DIFFERENT FORMS OF MENTAL DERANGEMENT. 93 brave the dangers of pestilence should support him in this duty beneath the assaults of pestilent tongues and pens. Not the voice of the people calling for executions, nor the severities of the bench frowning down psychological truth, should shake his purpose as an inquirer and a witness. His business is to de- clare the truth. Society must deal with the truth as it pleases." (Conolly.) In the following chapters I shall limit myself to a consideration of those forms of mental derange- ment concerning which doubts and disputes arise, and to the discussion in relation to them of the value of the criterion of responsibility which is adopted in courts of justice. I shall not, as would be proper in a treatise on insanity, describe in detail the dif- ferent forms, but shall discuss the popular and legal aspects of them in the light of medical observation. It will be most convenient, therefore, to adopt the simplest names by wThich they are commonly known, without regard to a more scientific nomenclature. Before entering upon this task, however, it is neces- sary to set forth what are the legal views of respon- sibility in regard to insanity. In the preceding chapters the aspects of medical inquiry have been sufficiently displayed; it remains now to describe the legal doctrines, to show how they have devel- oped into their present form, and to point out how they stand related to the results of scientific obser- vation. CHAPTER IV. LAW AND INSANITY. 1. 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 Jus- tice 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 by the 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 re- sponsibility—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—Un- certainty of result in English trials where insanity is alleged —The dicta of American judges: cases of Boardman v. Woodman, State v. Jones, and State v. Pike—Articles of the French penal code and of the latest German penal code —Comment upon the right-and-wrong theory of responsi- bility. 2. Former legal views of testamentary capacity: cases of Cart- wright v. Cartwright, Dew v. Clarke, and Waring v. War- ing—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. 94 LAW AND INSANITY. 95 1. Criminal Responsibility. Looking back at the strange and erroneous no- tions which were formerly entertained of the nature and causes of insanity, and considering what little observation was made of its manifold varieties, we cannot wonder that its jurisprudence was in a very defective state. At first two kinds of insanity only seem to have been recognised by English law—idiocy and lunacy: the idiot who, from his nativity, by a perpetual infirmity is non compos, and the lunatic, who hath sometimes his understanding, and some- times not, aliguando gaudet lucidis intervallis, and therefore is non compos mentis, so long as he hath not understanding. But as time went on a partial insanity was recognised as distinct from total insan- ity, although this partial insanity was declared not to absolve a person from responsibility for his crim- inal acts. " There is," says Lord Hale, " a partial insanity, and a total insanity. The former is either in respect to things, quoad hoc vel illud insanire. Some persons that have a competent use of reasou in respect of some subjects, are yet under a par- ticular dementia in respect of some particular dis- courses, subjects, or applications;—or else it is par- tial in respect of degrees; and this is the condition of very many, especially melancholy persons, who for the most part discover their defect in excessive fears and griefs, and yet are not wholly destitute of the use of reason; and this partial insanity seems not to excuse them in the committing of any offence 96 RESPONSIBILITY IN MENTAL DISEASE. for its matter capital; for, doubtless, most persons that are felons of themselves and others are under a degree of partial insanity when they commit these offences. It is very difficult to define the invisible line that divides perfect and partial insanity ; but it must rest upon circumstances duly to be weighed by judge and jury, lest, on the one side, there be a kind of inhumanity towards the defects of human nature; or, on the other side, too great an indul- gence given to great crimes." The invisible line which it was so difficult to define was not, let it be noted, between sanity and insanity, but between perfect and partial insanity. It was thought no in- humanity towards the defects of human nature to punish as a fully responsible agent a person who was suffering from partial insanity, whatever influ- ence the disease might have had upon his unlawful act. The principle thus laid down by Lord Hale was subsequently acted upon in English courts. Thus, in the trial of Arnold, an undoubted lunatic, for shooting at Lord Onslow, in 1723, Mr. Justice Tracy said, " It is not every kind of frantic humour, or something unaccountable in a man's actions, that points him out to be such a madman as is exempted from punishment: it must be a man that is totally deprived of his understanding and memory, and doth not know what he is doing, no more than an infant, than a brute or a wild beast; such a one is never the object of punishment." In this respect a wide distinction was maintained between civil and LAW AND INSANITY. 97 criminal cases; for while the law would not allow exemption from punishment for criminal acts unless the reason was entirely gone, it invalidated a per- son's civil acts, and deprived him of the manage- ment of himself and his affairs, when his insanity was only partial, and when the act voided had no discoverable relation to it. A man's intellect might not be sufficient to enable him to conduct his affairs, and to dispose of his property, though quite sufficient to make him responsible for a criminal act: it was right to hang for murder one who was not thought fit to take care of himself and his affairs. It was at the trial of Hadfield, in 1800, for shoot- ing at the King in Drury Lane Theatre, that Lord Hale's doctrine was first discredited, and a step for- ward made for the time. The Attorney-General, who prosecuted, had appealed to this doctrine, and told the jury, in accordance with it, that to exempt a person from punishment on the ground of insani- ty, there must be a total deprivation of memory and understanding. Mr. Erskine, who was counsel for the defence, argued forcibly in reply, that if such words were taken in their literal sense, "no such madness ever existed in the world ;" that in all the cases that had filled Westminster Hall with compli- cated considerations, "the insane persons had not only had the most perfect knowledge and recollec- tion of all the relations they stood in towards others, and of the acts and circumstances of their lives, but had in general been remarkable for subtlety and acuteness; and that delusion, of which the criminal 98 RESPONSIBILITY IN MENTAL DISEASE. act in question was the immediate unqualified off- spring, was the kind of insanity which should right- ly exempt from punishment. Delusion, therefore, where there is no frenzy or raving madness, is the true character of insanity." There was no doubt that Hadfield knew right from wrong, and that he was conscious of the nature of the act before he committed it; he manifested design in planning and cunning in executing it; he expected also that • it would subject him to punishment, for this was his motive in committing it; still it was plain to every- body that he was mad and that the act was the product of his madness. The result was that he was acquitted, the acquittal not having taken place in consequence of a judicial adoption of delusion in place of the old criterion of responsibility, as it has sometimes been said, but having been rather a tri- umph of Erskine's eloquence, and of common sense over legal dogma. In the next remarkable case, that of Bellingham, who was tried for the murder of Mr. Spencer Per- ceval, in 1812, a conviction took place, and the pris- oner was executed, although it was perfectly clear that he had acted under the influence of insane delusions; the Attorney-General, who prosecuted, declaring, and Chief Justice Mansfield, who tried the case, concurring, "upon the authority of the first sages in the country, and upon the authority of the established law in all times, which has never been questioned, that although a man might be in- capable of conducting his own affairs, he may still LAW AND INSANITY. 99 be answerable for his criminal acts, if he possess a mind capable of distinguishing right from wrong." Note here, then, that a modification had now been made in the test of responsibility; in place of its being required that the sufferer, in order to be ex- empt from punishment, should be totally deprived of understanding and memory, and know not what he was doing, no more than a brute or a wild beast —in place, that is, of what might be called the " wild beast " form of the knowledge test, the power of distinguishing right from wrong was insisted on as the test of responsibility. The law had changed considerably without ever acknowledging that it had changed. Let it be observed, however, that it was the power of distinguishing right from wrong, not in relation to the particular act, but generally, which was made the criterion of responsibility in this case; for Lord Mansfield, speaking of the kind of insanity in which the patient has the delusion of being in- jured, and revenges himself by some hostile act, said that " if such a person were capable, in other respects, of distinguishing right from wrong, there was no excuse for any act of atrocity which he might com- mit under this description of derangement. It must be proved beyond all doubt that at the time he com- mitted the atrocious act, he did not consider that murder was a crime against the laws of God and nature." * * Dr. Ray thus comments upon this doctrine:—"That the insane mind is not entirely deprived of this power of moral dis- cernment, but on many subjects is perfectly rational and dis- 100 RESPONSIBILITY IN MENTAL DISEASE. Thus far it is evident that principle was chang- ing and practice was uncertain. After the old " wild beast" form of the knowledge test had been quietly abandoned, when the enunciation of it caused too violent a shock to the moral sense of mankind, plays the exercise of a sound and well-balanced mind, is one of those facts now so well established, that to question it would only display the height of ignorance and presumption. The first result, therefore, to which the doctrine leads is, that no man can successfully plead insanity in defence of crime; be- cause it can be said of no one who would have occasion for such a defence, that he was unable in any case to distinguish right from wrong. . . . The purest minds cannot express greater horror and loathing of various crimes than madmen often do, and from precisely the same causes. Their abstract conceptions of crime, not being perverted by the influence of disease, pre- sent its hideous outlines as they ever were in the healthiest con- dition ; and the disapprobation they express at the sight arises from sincere and honest convictions. The particular criminal act, however, becomes divorced in their minds from its relations to crime in the abstract; and being regarded only in connection with some favourite object which it may help to obtain, and which they see no reason to refrain from pursuing, is viewed, in fact, as of a highly laudable and meritorious nature. Herein, then, consists their insanity—not in preferring vice to virtue, in applauding crime and deriding justice, but in being unable to discern the essential identity of nature between a particular crime and all other crimes, whereby they are led to approve what, in general terms, they have already condemned. It is a fact, not calculated to increase our faith in the ' march of intel- lect,' that the very trait peculiarly characteristic of insanity has been seized upon as a conclusive proof of sanity in doubtful cases; and thus the infirmity that entitles one to protection, is tortured into a good and sufficient reason for completing his ruin."—" A Treatise on the Medical Jurisprudence of Insanity," 5th ed. pp. 26-28. LAW AND INSANITY. 101 we find two theories acted upon in practice: in the case of Hadfield the existence of delusion instigat- ing the criminal act was the reason of his acquittal; in Bellingham's case, an absence of knowledge of right and wrong generally, not in respect of the particular act, was deemed necessary to exempt the individual from punishment; the latter theory being entirely inconsistent with the former, and neither of them being consistently acted upon in subsequent trials. Most often a knowledge of right and wrong, without reference to the particular act, was plainly declared by the judge to be the simple and sufficient criterion of responsibility, and the jury was in- structed accordingly; but this criterion was some- times modified by the qualifications which judges introduced to meet their individual views, or to prevent the conviction of a person who was plainly insane and irresponsible. There was no settled principle, no actual uniformity of practice, no cer- tainty of result. In this uncertain way matters went on until a great sensation was made by the murder, in 1843, of Mr. Drummond by McNaughten, who shot him under the influence of a delusion that he was one of a number of persons whom he believed to be follow- ing him everywhere, blasting his character and mak- ing his life wretched. McNaughten had transacted business a short time before the deed, and had shown no obvious symptoms of insanity in his ordinary dis- course and conduct. He was, however, acquitted on the ground of insanity. Thereupon the House of 8 102 RESPONSIBILITY IN MENTAL DISEASE. Lords, participating in the public alarm and indig- nation which were occasioned by the acquittal, pro- pounded to the judges certain questions with regard to the law on the subject of insanity when it was alleged as a defence in criminal actions; the object being to obtain from them an authoritative exposi- tion of the law for the future guidance of courts. The answers of the judges to the questions thus put to them constitute the law of England as it has been applied since to the defence of insanity in criminal trials. It is not necessary to quote the questions and answers at length ; the latter are somewhat con- fused, and the substance of them may be correctly given in fewer words. " To establish a defence on the ground of insanity, it must be clearly proved that at the time of committing the act the party accused was labouring under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or, if he did know it, that he did not know he was doing what was wrong." It will not escape atten- tion that the question of right and wrong in the abstract was here abandoned, being allowed quietly to go the way of the wild-beast form of the knowl- edge-test ; the question of right and wrong was to be put in reference to the particular act with which the accused was charged. Moreover, it was to be put in reference to the particular act at the time of committing it. Did he at the time know the nature and quality of the act he was doing ? These two LAW AND INSANITY. 103 points have been overlooked sometimes by hostile critics, who have condemned the rule enunciated, as though it referred to a knowledge of right and wrong generally. One may object to the rule as a bad one, and because it is calculated to mislead a jury, who are very likely to be misled by the exist- ence of a general knowledge of right and wrong in the accused person to judge wrongly concerning his knowledge of the particular act at the time, but it must be allowed at the same time that it will, if strictly applied, cover and excuse many acts of in- sane violence. Of few insane persons who do vio- lence can it be truly said that they have a full knowledge of the nature and quality of their acts at the time they are doing them. Can it be truly said of any person who acts under the influence of great passion that he has such a knowledge at the time ? The rule thus laid down, differing so much from that which was enunciated and mercilessly acted upon in Bellingham's sad case, was, however, lim- ited in its application by a formidable exception. In reply to the question—" If a person, under an insane delusion as to existing facts, commits an offence in consequence thereof, is he thereby ex- cused ?"—the judges declared that " on the as- sumption that he labours under partial delusion only (whatever that may mean), and is not in other respects insane, he must be considered in the same situation as to responsibility as if the facts with re- spect to which the delusion exists were real. For example, if, under the influence of delusion, he 104 RESPONSIBILITY IN MENTAL DISEASE. supposes another man to be in the act of attempt- ing to take his life, and he kills that man, as he supposes, in self-defence, he would be exempt from punishment. If his delusion was that the deceased had inflicted a serious injury to his character and fortune, and he killed him in revenge for such sup- posed injury, he would be liable to punishment." Here is an unhesitating assumption that a man, having an insane delusion, has the power to think and act in regard to it reasonably ; that, at the time of the offence, he ought to have and to exercise the knowledge and self-control which a sane man would have and exercise, were the facts with respect to which the delusion exists real; that he is, in fact, bound to be reasonable in his unreason, sane in his insanity. The judges thus actually bar the applica- tion of the right and wrong criterion of responsi- bility to a particular case, by authoritatively pre- judging it; instead of leaving the question to the jury, they determine it beforehand by assuming the possession of the requisite knowledge by the accused person. One of them, however, Mr. Justice Maule, so far dissented as to maintain that the general test of capacity to know right from wrong in the ab- stract ought to be applied to this case as to other cases. But this is not all the uncertainty which appears in these answers. In another part of them it is said, in reference to the same supposed case, that " notwithstanding the party accused did the act complained of with a view, under the influence of LAW AND INSANITY. 105 insane delusion, of redressing or revenging some supposed grievance or injury, or of producing some public benefit, he is nevertheless punishable, if he knew at the time of committing such crime that he was acting contrary to the law, by which is meant the law of the land." This answer really conflicts with a former answer; it is obvious that the knowl- edge of right and wrong is different from the knowledge of an act being contrary to the law of the land; and it is certain that an insane person may do an act which he knows to be contrary to law, because, by reason of his insanity, he believes it to be right, because, under the influence of insane delusion, he is a law unto himself, and deems it a duty to do it, perhaps " with a view of producing some public benefit." The uprightness of English judges has happily been seldom called in question, but it may well be doubted whether the result of their solemn delib- erations, as embodied in their answers to the ques- tions put to them by the House of Lords, will commend their wisdom to the approbation of for- eign nations and future ages. If it be true, as is sometimes said, that the verdict of foreign nations is an anticipation of the verdict of posterity, there are already sufficiently strong indications that their conclusions will be no honour to them in times to come. That they are unanimously condemned by all physicians who have a practical knowledge of the insane, may not affect the confidence of those who accept them, seeing that judges and physicians 106 RESPONSIBILITY IN MENTAL DISEASE. take such different stand-points; but when the judges of other countries condemn them with equal earnestness, it is impossible for the most confident to help feeling some hesitation. In the case of State v. Jones, tried in the court of New Hampshire, America, Judge Ladd, after passing in review the answers of the English judges, thus speaks of the doctrine embodied in them :— " The doctrine thus promulgated as law has found its way into the text books, and has doubtless been largely received as the enunciation of a sound legal principle since that day. Yet it is probable that no ingenious student of the law ever read it for the first time without being shocked by its exquisite inhu- manity. It practically holds a man confessed to be insane, accountable for the exercise of the same reason, judgment, and controlling mental power that is re- quired in perfect mental health. It is, in effect, say- ing to the jury, the prisoner was mad when he com- mitted the act, but he did not use sufficient reason in his madness. He killed a man because, under an in- sane delusion, he falsely believed the man had done him a great wrong, which was giving rein to a motive of revenge, and the act is murder. If he had killed a man only because, under an insane delusion, he falsely believed the man would kill him if he did not do so, that would have been giving the rein to an instinct of self preservation, and would not be crime. It is true in words the judges attempt to guard against a conse- quence so shocking as that a man may be punished for an act which is purely the offspring and product of insanity, by introducing the qualifying phrase, " and LAW AND INSANITY. 1Q7 is not in other respects insane." That is, if insanity produces the false belief, which is the prime cause of the act, but goes no further, then the accused is to be judged according to the character of motives which are presumed to spring up out of that part of the mind which has not been reached or affected by the delusion or the disease. This is very refined. It may be that mental disease sometimes takes a shape to meet the provisions of this ingenious formula; or, if no such case has ever yet existed, it is doubtless within the scope of Omnipotent power hereafter to strike with disease some human mind in such peculiar manner that the conditions will be fulfilled; and when that is done, when it is certainly known that such a case has arisen, the rule may be applied without punishing a man for disease. That is, when Ave can certainly know that although the false belief on which the prisoner acted was the product of mental disease, still that the mind was in no other way impaired or affected, and that the motive to the act did certainly take its rise in some portion of the mind that was yet in perfect health, the rule may be applied without any apparent wrong. But it is a rule which can safely be applied in practice that we are seeking ; and to say that an act which grows wholly out of an insane belief that some great wrong has been inflicted, is at the same time produced by a spirit of revenge springing from some portion or corner of the mind that has not been reached by the disease, is laying down a pathological and psychological fact which no human intelligence can ever know to be true, and which, if it were true, would not be law, but pure matter of fact. No such distinction ever can or ever will be drawn into prac- 108 RESPONSIBILITY IN MENTAL DISEASE, tice; and the absurdity as well as the inhumanity of the rule seems to me sufficiently apparent without further comment, . . . It is a question of fact whether any universal test exists, and it is also a question of fact what that test is, if any there be." * Since the answers of the judges were made to the House of Lords the law as relating to insanity in a criminal trial has been laid down in conformity with their conclusions : if the accused person at the time of committing the offence knew right from wrong, and that he was doing wrong, he must be brought in guilty, whether insane or not. If insane, he is not necessarily exempted from the punishment of his crime; the question is, whether he was at the time capable of committing a crime; and that must be determined by evidence of the absence, not of insanity, but of a knowledge of right and wrong. Was his insanity of such a kind as to render him irresponsible by destroying his knowledge of right and wrong ? Nevertheless, juries often, and judges occasionally, out of a natural humanity repudiate this dogma in particular cases, and so far from any certainty of result having been secured by its appli- cation, it is notorious that the acquittal or conviction of a prisoner, when insanity is alleged, is a matter of chance. Were the issue to be decided by tossing up a shilling, instead of by the grave procedure of a trial in court, it could hardly be more uncertain. The less insane person sometimes escapes, while the State v. Jones, p. 388. LAW AND INSANITY. 109 more insane person is sometimes hanged; one man labouring under a particular form of derangement is acquitted at one trial, wdiile another having an exactly similar form of derangement is convicted at another trial. No one will be found to uphold this state of things as satisfactory, although there is great difference of opinion as to the cause of the uncer- tainty ; the lawyers asserting that it is owing to the fanciful theories of medical men who never fail to find insanity where they earnestly look for it, the latter protesting that it is owing to the unjust and absurd criterion of responsibility which is sanctioned by the law. Meanwhile, it is plain that, under the present system, the judge does actually withdraw from the consideration of the jury some of the essential facts, by laying down authoritatively a rule of law which prejudges them ; the medical men tes- tify to facts of their observation in a matter in which they alone have adequate opportunities of observa- tion ; the judge, instead of submitting these facts to the jury for them to come to a verdict upon, repu- diates them by the authority of a so-called rule of law, which is not rightly law, but is really false in- ference founded on insufficient observation. In America it would seem that matters have been little better than they are in this country, the practice of the courts, like that of the British courts, having been diverse and fluctuating. In many in- stances juries have been instructed, in accordance with English legal authorities, that if the prisoner, at the time of committing the act, knew the nature 110 RESPONSIBILITY IN MENTAL DISEASE. and quality of it, and that in doing it he was doing wrong, he must be held responsible, notwithstand- ing that on some subjects he may have been insane; that in order to exempt a person from punishment insanity must be so great in extent or degree as to destroy his capacity of distinguishing between right and wrong in regard to the particular act. But in other instances the instructions of the judges have been different. In the case of State v. Wier, Graf- ton 60, 1864, Chief Justice Bell charged the jury thus:— " The evidence must satisfy the jury that the party at the time of committing the act in question was in- sane, and that the disease is of such severity that the person is incapable of distinguishing between right and wrong in that particular case, or of controlling the sudden impulse of his own disordered mind; or, as the same rule has been laid down by an eminent judge, a person, in order to be punishable by law, must have sufficient memory, intelligence, reason, and will, to enable him to distinguish between right and wrong in regard to the particular act about to be done, to know and understand that it will be wrong, and that he will deserve punishment by committing it; to which I add sufficient mental power to control the sud- den impulses of his own disordered mind. ... I have been accustomed to regard as the distinguishing test of insanity the inability to control the actions of a man's mind. . . . The power of the control of the thoughts being lost, the power of the will over the conduct may be equally lost, and the party under the influence of disease acts not as a rational being, but LAW AND INSANITY. Ill under the blind influence of evil thoughts which he can neither regulate nor control. It was, perhaps, not without reason that in ancient times the insane were spoken of as possessed with an evil spirit, or possessed with a devil, so foreign are the impulses of that evil spirit to all the natural promptings of the sane heart and mind." * In the case of Stevens v. the State of Indiana, the instruction to the jury that if they believed the defendant knew the difference between right and wrong in respect of the act in question, if he was conscious that such act was one which he ought not to do, he was responsible—was held to be erro- neous. It would appear, then, that the American courts which, having inherited the Common Law of Eng- land, at first followed docilely in the wake of the English courts, are now exhibiting a disposition to emancipate themselves from an authority which they perceive to be founded on defective and erro- neous views of insanity, and a desire to bring the law more into accordance with the results of scien- tific observation. The decisions of the Court of New Hampshire in Boardman v. Woodman, State v. Jones, and State v. Pike, are especially worthy of attention for their searching discussion of the rela- tions of insanity to jurisprudence, and for the de- cisive abandonment of the right and wrong test of responsibility. In the case of State v. Pike, Chief * Quoted in the Report of State v. Jones, pp. 376, 377. 112 RESPONSIBILITY IN MENTAL DISEASE. Justice Perley instructed the jury that they should return a verdict of not guilty " if the killing was the offspring of mental disease in the defendant; that neither delusion nor knowledge of right and wrong, nor design or cunning in planning and exe- cuting the killing, and in escaping or avoiding de- tection, nor ability to recognise acquaintance, or to labour or transact business or manage affairs, is, as a matter of law, a test of mental disease; but that all symptoms and all tests of mental disease are purely matters of fact to be determined by the jury." " A striking and conspicuous want of success," said Judge Doe in the same case, " has attended the efforts made to adjust the legal relations of mental disease. ... It was for a long time supposed that men, however insane, if they knew an act to be wrong, could refrain from doing it. But whether that sus- picion is correct or not, is a pure question of fact; in other words, a medical supposition,—in other words, a medical theory. Whether it originated in the medical or any other profession, or in the general notions of mankind, is immaterial. It is as medical in its nature as the opposite theory. The knowledge test in all its forms, and the delusion test, are medical theories in- troduced in immature stages of science, in the dim light of earlier times, and subsequently, upon more extensive observations and more critical examinations, repudiated by the medical profession. But legal tri- bunals have claimed these tests as immutable princi- ples of law, and have fancied they were abundantly vindicated by a sweeping denunciation of medical theories—unconscious that this aggressive defence was LAW AND INSANITY. 113 an irresistible assault on their own position. ... In this manner opinions, purely medical and pathological in their character, relating entirely to questions of fact, and full of errors, as medical experts now testify, passed into books of law, and acquired the force of judicial decisions. Defective medical theories usurped the position of common-law principles. . . . "Whether the old or the new medical theories are correct, is a question of fact for the jury; it is not the business of the court to know whether any of them are correct. The law does not change with every advance of sci- ence ; nor does it maintain a fantastic consistency by adhering to medical mistakes which science has cor- rected. The legal principle, however much it may formerly have been obscured by pathological darkness and confusion, is that a product of mental disease is not a contract, a will, or a crime. It is often difficult to ascertain whether an individual has a mental dis- ease, and whether an act was the product of that dis- ease; but these difficulties arise from the nature of the facts to be investigated, and not from the law; they are practical difficulties to be solved by the jury, and not legal difficulties for the court." * These American decisions are certainly an ad- vance on any judgment concerning insanity which has been given in this country; they put in a proper light the relations of medical observation and law in questions of mental disease; and it cannot be doubted that future progress will be along the path * See also p. 441 and following pages for further weighty ob- servations on this matter. 114 RESPONSIBILITY IN MENTAL DISEASE. which they have marked out. The question which will probably be submitted to the jury will be sub- stantially—Was the act the offspring or product of mental disease ?—and it will be seen that to lay down any so-called test of responsibility founded on a supposed knowledge of right and wrong, is, as Judge Ladd remarked in State v. Jones, " an inter- ference with the province of the jury, and the enunciation of a proposition which, in its essence, is not law, and which could not in any view safely be given to the jury as a rule for their guidance, be- cause, for aught we can know, it may be false in fact." Seeing, then, that by the unanimous testi- mony of medical men of all countries who have been practically acquainted with insanity, it is de- clared positively that such a proposition is false in fact, it is clear that the law, in enunciating it, is not only overstepping its rightful function, but actually perpetrating an injustice. It is simply doing in re- gard to insanity what it did formerly in regard to witchcraft—giving erroneous opinions on matters of fact to the jury under the name of law, and with all the weight of judicial authority. In one of the latest trials for witchcraft in this country, Lord Hale, whose crude dicta concerning insanity were so long acted upon in our courts of justice, in- structed the jury—" That there are such creatures as witches he made no doubt at all. For, first, the Scriptures had affirmed so much. Secondly, the wisdom of all nations had provided laws against such persons, which is an argument of their confi- LAW AND INSANITY. H5 dence of such a crime." The jury accordingly found a verdict of guilty; the judge, satisfied with it, condemned the prisoners to death, and they were executed. It was one of the last executions for witchcraft in this country, for it occurred at a time —and this should never be forgotten—when the be- lief in witchcraft was condemned by the enlight- ened opinion of the country. As it was then with witchcraft, so it is now with insanity: the judge in- structs the jury wrongly on matters of fact; they find accordingly a verdict of guilty; he is satisfied with the verdict, and an insane person is executed. The falseness of the legal position will appear at once if we suppose a case of poisoning instead of a case of mental derangement: what would be thought of a judge who, when medical evidence of poison- ing was given, should instruct the jury as a prin- ciple of law that they must be governed in their verdict by the presence or absence of a particular symptom ? " If the tests of insanity are matters of law, the practice of allowing experts to testify what they are should be discontinued; if they are mat- ters of fact, the judge should no longer testify with- out being sworn as a witness and showing himself qualified to testify as an expert." * But, in truth, the tests of insanity are no more matters of law than are the tests of a poison or the symptoms of disease. " If a jury were instructed that certain manifesta- tions were symptoms or tests of consumption, chol- era, congestion, or poison, a verdict rendered in * Judge Doe, State v. Pike. 116 RESPONSIBILITY IN MENTAL DISEASE. accordance with such instructions would be set aside, not because they were not correct, but be- cause the question of their correctness was one of fact to be determined by the jury upon evidence." * Other nations have not bound themselves by so narrow and ill-founded a criterion of responsibility in insanity; they have refrained from the attempt to define exactly the conditions of responsibility. In France the article of the penal code is—" There can be no crime nor offence if the accused was in a state of madness at the time of the act." And the revised statutes of the State of New York enact, that " no act done by a person in a state of insan- ity can be punished as an offence." These general enactments, while wisely leaving each case to be decided on its merits, may clearly be construed, if they were not intended, to exempt from punishment the individual who, being partially insane, neverthe- less commits a crime which is no way connected with his insanity; who, in fact, so far as can be judged, does it in the same way and from exactly the same motive as a sane person. For an insane person is not exempt from the ordinary evil passions of human nature ; he may do an act out of jealousy, avarice, or revenge: is it right, then, when, so far as appears, the passion is not connected with his diseased ideas or feelings, and he acts with criminal intent, that he should escape punishment for what he has done ? This is really the important question which must continue to puzzle courts of justice when * Boardman v. Woodman. LAW AND INSANITY. 117 a particular criterion of responsibility is no longer laid down; for if it be admitted that an insane per- son who apparently does a criminal act sanely ought not to escape punishment, the difficulty of deciding whether his disease did or did not affect the act will remain. There will always be room enough for doubts and differences of opinion. The section of the latest German penal code is: —" An act is not punishable when the person at the time of doing it was in a state of unconsciousness or of disease of mind, by which a free determination of the will was excluded." Not every disorder of mind is exempt; only such actual disease as ex- cludes a free determination of the will. The prob- lem then is to determine, first, what conditions of derangement of the mental faculties are to be con- sidered as the result of disease; and, secondly, whether and how far free-will is excluded by them. In the case of a partially insane person acting to all appearances from an ordinary criminal motive, the act must be weighed in relation to these two ques- tions ; and if they are answered in the negative, he would clearly be amenable to punishment. It is abundantly evident from this short review of the codes of other countries that nothing can be said in justification of the superstitious reverence with which English lawyers cling to their criterion of responsibility.* It is hard to see why they should * Described by one of the latest German commentators upon it as Ein Irrthum der heutzutage noch in der Englisehen Ge- setzgebung und Rechtsprechung besteht und unzahlige Justiz- 9 118 RESPONSIBILITY IN MENTAL DISEASE. suffer a greater pang in giving up this formula than they did in giving up other formulas which, having had their day and done much evil work, were aban- doned. The " wild-beast theory," once so sacred, has been relegated to the record of human mistakes; the theory of a knowledge of right and wrong in the abstract which followed it was, in like manner, repudiated as men became better acquainted with the phenomena of mental derangement; surely then the metaphysical theory of a knowledge of right and wrong in relation to the particular offence, which finds little or no favour out of England, and which is condemned unanimously by all persons in all countries who have made insanity their study, may be suffered to join its predecessors, without danger of injury to what all those who approve and those who disapprove it desire—the strict administration of justice. Physicians have no right to interfere in the administration of the law, which is the judge's function, nor is it their duty to decide upon what is necessary to the welfare of the state, that be- ing the legislator's work; their concern is with the individual not with the citizen. But they plainly have the right to declare that the nature of a crime involves two elements, first, the knowledge of its being an act contrary to law, and, secondly, the will to do or to forbear doing it, and to point out that there are some insane persons who, having the morde verschuldet hat—an error which at this day still exists in English jurisprudence and has been the cause of countless judicial murders. LAW AND INSANITY. 119 former, are deprived by their disease of the latter; who may know an act to be unlawful but may be impelled to do it by a conviction or an impulse which they have not the will or the power to resist. Recognising the obvious difference between him who will not and him who cannot fulfil the claims of the law, it is their function to point out the con- ditions of disease which constitute incapacity, and when they find a false fact solemnly enunciated as a rule of law, to bring forward into all the promi- nence they can the contradictory instances which their observation makes known to them. "That cannot be a fact in law which is not a fact in science; that cannot be health in law which is disease in fact. And it is unfortunate that courts should maintain a contest with science and the laws of nature upon a question of fact which is within the province of science and outside the domain of law." * 2. Testamentary Capacity. Thus much concerning the application of the law to the allegation of insanity for the defence in a criminal trial. When the question before the courts has been one of testamentary capacity, the view taken of the effect of mental derangement has been different from that which has found fa- * Judge Doe—Boardman v. Woodman. " If it is neces- sary that the law should entertain a single medical opinion concerning a single disease, it is not necessary that that opinion should be a cast-off theory of physicians of a former genera- tion."—P. 150. 120 RESPONSIBILITY IN MENTAL DISEASE. vour when the question was one of criminal respon- sibility. Uncertainty and confusion have, however, long prevailed, and it is only quite recently that definite principles have been authoritatively laid down. Formerly, it was held that if a testator, though insane, made a natural and consistent dis- tribution of his property, a lucid interval at the moment of making the will might be justly pre- sumed. " For, I think," said Sir William Wynne in Cartwright v. Cartwright, " the strongest and best proof that can arise as to a lucid interval is that which arises from the act itself; that I look upon as the thing to be first examined ; and if it can be proved and established that it is a rational act ra- tionally done, the whole case is proved." To the same effect are the remarks of Swinburne :—" If a lunatic person or one that is beside himself at some times, but not continually, make his testament, and it is n^pt known whether the same were made while he was of sound mind and memory, or no, then in case the testament be so conceived as thereby no argument of phrenzy or folly can be gathered, it is to be presumed that the same was made during the time of his calm and clear intermission, and so the testament shall be adjudged good; yea, although it cannot be proved that the testator useth to have any clear and quiet intermissions at all, yet never- theless I suppose that if the testament be wisely and orderly framed, the same ought to be accepted for a lawful instrument. So, on the other hand, if there be any mixture of wisdom and folly, it is LAW AND INSANITY. 121 to be presumed that the same was made during the testator's phrenzy, even if there be but one word sounding to folly." Thus it might happen, in ac- cordance with this principle, that a man who was acknowledged to be incapable of managing his affairs, would be deemed competent to dispose of his property by will, if the will contained no word " sounding of folly," but seemed " a rational act rationally done." It was presumed that the same integrity and vigour of mind were not required for an act which might be done quietly and de- liberately, at a favourable time, as for the general conduct of life. The leading case in regard to testamentary capacity, which has had a great authority, was that of Dew v. Clarke, in which Sir John Nicholl, striving to enunciate a definite criterion, said,— " The true criterion—the true test—of the ab- sence or presence of insanity, I take to be the absence or presence of what, used in a certain sense of it, is comprehended in a single term, namely, delusion. Wherever the patient once con- ceives something extravagant to exist, which has still no existence but in his own heated imagina- tion, and wherever, at the same time, having once so conceived, he is incapable of being, or at least of being permanently, reasoned out of that conception —such a patient is said to be under a delusion, in a peculiar half technical sense of the term ; and the absence or presence of delusion, so understood, forms, in my judgment, the true and only test or 122 RESPONSIBILITY IN MENTAL DISEASE. criterion of absent or present insanity. In short, I look upon delusion, in this sense of it, and insanity to be almost, if not altogether, convertible terms; so that a patient under a delusion, so understood, on any subject or subjects, in any degree, is, for that reason, essentially mad or insane on such subject or subjects, in that degree." He then went on to point out that in the case under consideration the will was the direct, unqualified offspring of the morbid delusion, "the very creature of that mor- bid delusion put into act and energy," and decided consequently that it was null and void in law. All that the decision actually established was that a dis- posal of property which was the direct, unqualified offspring of morbid delusion, was null and void. Nevertheless, the decision has often been quoted, as though it laid down the principle that delusion upon any subject, however remote from and uncon- nected with the subject of the will, was conclusive evidence of unsoundness of mind sufficient to in- validate the will. It is true that Sir John Nicholl declared delusion to be the true and only test of the presence of insanity, and so went out of his way to enunciate a general principle which is not founded on fact, but the actual principle of his de- cision in the particular case was limited as stated, and cannot be cavilled at. It was this and no more: the direct product of an insane delusion is not a valid will. The opinion that delusion, however circum- scribed, voids a will, although the will can in no LAW AND INSANITY. 123 way be connected with the influence of it, has been acted upon in some judicial decisions. " Delusion, therefore, when there is no frenzy or raving mad- ness," said Lord Erskine, " is the true character of insanity. In civil cases, as I have already said, the law voids every act of the lunatic during the period of lunacy, although the delusion may be extremely circumscribed, although the mind may be quite sound in all that is not within the shades of the partial eclipse, and although the act to be voided can in no way be connected with the influence of the insanity ; but to deliver a lunatic from respon- sibility to criminal justice, above all, in a case of atrocity, the relation between the disease and the act should be apparent." * In the case of Waring v. Waring, the Judicial Committee of the Privy Council, and in the case of Smith v. Tibbett, Lord Penzance laid down the doctrine that mental un- soundness, though unconnected with the testamen- tary disposition, destroyed testamentary capacity. In both these cases, however, there was really a general derangement of mind ; in both the delu- sions had influenced the dispositions of property; and in both, as Chief-Justice Cockburn has re- marked, " there existed ample grounds for setting aside the will without resorting to the doctrine in question." The doctrine has since been rejected judicially. * Quoted by Dr. Prichard in his work " On the Different Forms of Insanity in Relation to Jurisprudence." 124 RESPONSIBILITY IN MENTAL DISEASE. This happened first in the case of Boardman v. Woodman, in the Court of New Hampshire, United States. In this case Judge Bartlett charged the jury "that the mere fact of the possession of a delusion may not be sufficient to render a person utterly incapable of making a valid will; that a per- son of sufficient mental capacity, though under a delusion, may make a valid will: if the will is no way the offspring of the delusion, it is unaffected by it." This ruling, which was confirmed on appeal, has been since followed in this country by the full Court of Queen's Bench, in the case of Banks v. Goodfellow. In the course of an elaborate judg- ment of the Court which Chief-Justice Cockburn delivered, he said:— " Every one must be conscious that the faculties and functions of the mind are various and distinct as are the powers and functions of the physical organization. The instincts, the affections, the passions, the moral sense, perceptions, thought, reason, imagination, mem- ory, are so many distinct faculties or functions of the mind. The pathology of mental disease, and the ex- perience of insanity in its various forms, teach us that, while on the one hand all the faculties, moral and in- tellectual, may be involved in one common ruin, as in the case of a raving maniac, one or more only of these faculties or functions may be disordered, while the rest are left unimpaired and undisturbed; that while the mind may be overpowered by delusions which utterly demoralize and unfit it for the perception of the true nature of surrounding things, or for the discharge of LAW'AND INSANITY. 125 the common obligations of life, there often are, on the other hand, delusions which, though the offspring of mental disease, leave the individual in all other re- spects rational and capable of transacting the ordinary affairs, and fulfilling the duties and obligations inci- dental to the various relations of life. . . . No doubt when the fact that the testator had been subject to any insane delusion is established, a will should be re- garded with great distrust, and every presumption should in the first instance be made against it. When insane delusion has once been shown to have existed it may be difficult to say whether the mental disorder may not possibly have extended beyond the particular form or instance in which it has manifested itself. It may be equally difficult to say how far the delusion may not have influenced the testator in the particular disposal of his property; and the presumption against a will made under such circumstances becomes addi- tionally strong where the will is, to use the term of the civilians, an inofficious one, that is to say, one in which natural affection and the claims of near relationship have been disregarded. But when in the result the jury are satisfied that the delusion has not affected the general faculties of the mind, and can have had no effect upon the will, we see no sufficient reason why the testator should be held to have lost his right to make a will, or why a will made under such circum- stances should not be upheld. Such an inquiry may involve, it is true, considerable difficulty, and require much nicety of discrimination, but we see no reason to think that it is beyond the power of judicial investiga- tion and decision, or may not be disposed of by a jury directed or guided by a judge." 126 RESPONSIBILITY IN MENTAL DISEASE. He does not neglect to point out the obvioua necessity of guarding this doctrine by looking care- fully to the condition of the mental faculties in any such case:— " It is essential to the exercise of such a power that a testator should understand the nature of the act and its effects; shall understand the extent of the property of which he is disposing; shall be able to comprehend and appreciate the claims to which he ought to give effect; and, with a view to the latter object, that no disorder of the mind should poison his affections, per- vert his sense of right, or prevent the exercise of the natural faculties; that no insane delusion shall influ- ence his will in disposing of his property, and bring about a disposal of it which, if the mind had been sound, would not have been made. Here then we have the measure of the degrees of mental power which should be insisted upon. If the human in- stincts and affections, or the moral sense, become per- verted by mental disease: if insane suspicion or aver- sion take the place of natural affection, if reason and judgment are lost, and the mind becomes a prey to insane delusions calculated to interfere with and dis- turb its functions, and to lead to a testamentary dispo- sition due only to their baneful influence, in such a case it is obvious that the condition of the testamen- tary power fails, and that a will made under such cir- cumstances ought not to stand." This decision of the Court of Queen's Bench in Banks v. Goodfellow, which practically is that an insane man may sometimes make a sane will, agrees LAW AND INSANITY. 127 so far with the older decisions as that the will itself, if appearing to be a rational act rationally done, was held to be evidence of a lucid interval. Obviously, however, the difficulty of deciding whether the will has or has not been influenced by the insanity will sometimes be exceedingly great. For it is not alone the direct bearing of a delusion which should be weighed carefully in such a case, but it will be neces- sary to take into consideration also the disordered feelings which may be directly or indirectly con- nected with the delusion, and under the influence of which the will may have been made. Moreover, the deranged feelings may be themselves the off- spring of the mental disease without being connected with the delusion; they and it not being related as cause and effect, but being concomitant effects of a common cause. Insanity displaying itself in disor- dered feelings as well as in disordered thought, it is quite possible that a will might carry no evidence of the bearing of a delusion upon its provisions, and yet might witness to feelings which would have had no existence but for the disease. And it may justly be questioned whether a' jury, utterly ignorant of insanity, though directed and guided by a judge, whose knowledge of the disease is commonly no greater than theirs, is the most competent tribunal that could be devised for determining how far an insane delusion has affected the mental functions. They would certainly be in a much better position for coming to a right conclusion if they had for di- rection or guidance the benefit of a medical knowl- 128 RESPONSIBILITY IN MENTAL DISEASE. edge of the disease furnished to them, not by the parties interested in the trial, but in an independent manner by the court. We must wait for future decisions to learn whether the principle laid down in Banks v. Good- fellow is to govern the making of contracts by par- tially insane persons, or whether such contracts are to be voided in accordance with the old rule that the law voids every act of the lunatic, although the insanity may be extremely circumscribed, and al- though the act to be voided can in no way be con- nected with the influence of the insanity. Mean- while a partially insane person who gets married, and who has been clever enough to marry without being under the influence of delusion, must remain in doubt wdiether he is legally married or not. In concluding this chapter, it may be remarked that by the judgment of the Court of Queen's Bench the law relating to testamentary capacity and the law relating to criminal responsibility are made to agree so far as this—That a partially in- sane person is competent to make a will or to com- mit a crime; not being declared incapable in the one case, nor exempted from punishment in the other case, save when the act in question can be shown to be the offspring of insanity. But they differ in these points : first, that while an insane de- lusion of which a will is the offspring will invalidate it, an insane delusion of which a criminal offence is the offspring will not invalidate it in all cases; sec- ondly, that while disordered feelings springing from LAW AND INSANITY. 129 insanity have due weight given to them in estimat- ing the value of a will, no consideration is given to them in a criminal trial; and, thirdly, that while no special test of civil capacity is enunciated as a legal principle, the whole case being left to the jury to be decided upon its merits, a special test of responsibil- ity is proclaimed as a legal principle in criminal cases. In the United States, some recent decisions have been more consistent with sound law and with the conclusions of medical science. CHAPTER V. PARTIAL INSANITY. I.—Affective Insanity. Insanity comprises several forms of mental derangement;—Va- riations 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 : misinter- pretation of them by lawyers and others—Uselessness of the capital punishment of insane persons as an example to others. Affective insanity : 1. Impulsive insanity. Insane suicidal im- pulse or suicidal monomania: examples—Pathological na- ture 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 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 out- break : 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 in- sane 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 charac- teristic features and its causation—Moral alienation often 130 PARTIAL INSANITY. 131 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. It may seem quite superfluous to declare that insanity is disease ; but it is very far from being su- perfluous to set forth what is involved in that asser- tion. In the first place, insanity does not mean one disease to be diagnosed by a single mark, but a va- riety of diseases, each of which has its more or less characteristic features, its special course, and more or less special cause, and its particular termination. For some purposes it may be enough to say gener- ally that a person is insane, but such a vague state- ment is not scientific ; for medical purposes it is necessary to know under what form of mental de- rangement he labours. In the second place, each form of mental derangement has, like other diseases, its premonitory symptoms marking what might be called its stage of incubation, its early symptoms, variations in its course, and a termination which, according as it is good or bad, will be indicated by the different character of the symptoms. We must be prepared therefore for great variations both in the intensity and character of the symptoms at dif- ferent periods, and by no means expect to observe in all cases a steady course up to a certain intensity, and then a steady decline. These variations are ex- pressed by such terms as intermittent, remittent, periodic, which are applied to the different forms, 132 RESPONSIBILITY IN MENTAL DISEASE. according to their varying phases; particular symp- toms, that is, particular insane ideas, feelings and acts, often marking each phase of the disease. It will be necessary, therefore, to take into considera- tion the wdiole course and symptoms in any case, and not to conclude hastily either from a single symptom or from a particular phase. The early symptoms commonly differ consider- ably from those which are manifested at a later pe- riod of the disease; for the most part they are much less marked ; they may in fact be such as would by no means indicate to an unskilled observer that the person was the victim of mental alienation in any of its forms. A man, for example, exhibits an unusual depression for which there is no sufficient cause either in his social relations, or in the state of his affairs—no adequate external cause ; he takes no in- terest in his work, and thinks himself incapable of doing it, although other persons can see no reason why he cannot do it, or do not perceive that, when he makes the attempt, he does not do it as well as formerly; he is moody and low, perhaps sleepless at nights, or tormented with vivid dreams during snatches of unrefreshing slumber; but he has no delusion, nor is there anything irrational in his con- versation—he may discuss with intelligence his own affairs, and even his own condition. Nevertheless, these symptoms are the early symptoms of a mental disorder which, in its further course, may issue in positive delusion of thought, or in suicidal or homi- cidal violence. It is, indeed, from the gloomy depths PARTIAL INSANITY. 133 of a mind in this melancholic state that desperate impulses to suicide or homicide often spring; and it is by persons in this state of mental suffering that many of the suicides and some of the homicides which are recorded almost daily in the newspapers, are done. Take anothar instance :—A young lady, from sixteen to twenty years of age, begins to exhibit some unaccustomed peculiarities ; becomes fanciful about her health, or about the state of her feelings, believing that she is not living up to the ideal which she ought to reach and maintain ; cannot apply her- self steadily to her pursuits in life, or to the pleas- ures which are her pursuits ; spends much time alone in meditation or prayer, or in what passes for meditation or prayer; and perhaps becomes ca- pricious in her behaviour to her relations about her; they meanwhile see nothing to demand medical at- tention, or, if they notice anything strange, perhaps think to benefit her by the advice of some clergy- man. These are, however, the early symptoms of a form of mental derangement, which, if not checked by suitable treatment, is not unlikely to increase, and to pass soon into an incurable state. How often does it happen to the physician in active practice to be consulted about the evident insanity of some such patient, whose friends express the utmost surprise that she should so suddenly have fallen into so sad a state ! Ignorant of the meaning of the early symp- toms which had been exhibited for some time in an obscure and, so to speak, capricious way, they have 10 134 RESPONSIBILITY IN MENTAL DISEASE. overlooked them entirely, or have considered them of small importance and have only awakened to the serious state of matters when the disease was beyond the possibility of mistake, and perhaps beyond the possibility of cure. It is needless to multiply exam- ples ; for it is obvious that the early symptoms of disease may be such as would not lead an unskilled observer to suspect that the person was becoming insane, much less to declare that he was insane when a physician, knowing their true interpretation, would at once recognise their gravity. It should be borne in mind again that insanity is a disease which, even in its acute forms, has natu- rally a much longer course than ordinary bodily diseases have; while in them we count duration by hours and days, in it we count rather by weeks and months. As a rule certainly a person does not go mad in a few hours or days; on the contrary, he may take several weeks or months before he is clearly deranged. Now if while in this early stage of his disease he do some act which brings the ques- tion of his state of mind into a civil or criminal court, there may be occasion for much dispute con- cerning it. Lawyers, maintaining that he knew quite well what he was doing, will assert his entire responsibility; the physician, recognising the first symptoms of an approaching derangement, familiar by experience with its occasional sudden exacerba- tions, and its reasoning unreason, and knowing how little power of control there may be over the sud- denly arising morbid ideas or impulses, may prob- PARTIAL INSANITY. 135 ably uphold his irresponsibility. The one looks simply to the act itself, and to the evidence of con- sciousness in its execution, deriving its motive from the experience of the workings of a sane mind, and inferring malice aforethought; the other looks to the antecedent symptoms of disease, and to the loss of power of will wThich may be occasioned thereby, deriving his interpretation of the act from his experi- ence of the workings of an unsound mind. Doubtful cases difficult of decision cannot fail to occur from time to time ; cases which the physician, when he is obliged to give a name to them, is driven to call ex- amples of partial insanity, moral insanity, homicidal mania, kleptomania, and the like ; whereupon his testimony is subject to the easy retort that such kind of mania will be best treated by legal punish- ments—by the prison or the scaffold. The retort •may be effectual for the moment, but it is neither humane nor just. If the person be suffering from disease which lessens or destroys his power of self- control, it is manifestly not justice to him to treat him as if he were free from disease and were a com- pletely responsible agent. So far as he is concerned, he has surely the right to claim the privilege of his disease, and the compassion which attaches to af- fliction in civilized lands. This, however, may be admitted by those who take the legal view, and yet at the same time the punishment may be defended in the supposed inter- ests of society. Human justice, it will be said, can- not pretend or attempt to apportion the exact meas- 136 RESPONSIBILITY IN MENTAL DISEASE. ure of an individual's responsibility ; it is only above that the act in its true nature lies; here be- low we must rest satisfied practically with a rough standard of justice, looking in its application to the great interests of society, and must inflict punish- ment in order to deter others from crime. An English judge, in sentencing a prisoner to death for sheep-stealing when death was the punishment in- flicted with the object, but without the effect, of deterring persons from stealing sheep, is reported to have said:—" I do not sentence you to be hanged for stealing sheep, but in order that sheep may not be stolen." And another English judge, who is still on the bench, when sentencing to death for murder a madman on whose behalf insanity had been unsuccessfully pleaded, said that he was not sure whether it was not more necessary to hang an insane person than a sane person. The opinion, barbarous as it seems, was evidently based upon the belief that it was most necessary in the interests of society to deter insane persons from doing murder, and that the execution of them would act as a warn- ing to other madmen, and so deter them, if not from going mad, at any rate from doing murder when they were mad. If this were so, it would be a matter of just surprise that the practice of confin- ing lunatics in asylums has not availed to deter them from going mad, by acting as an effectual warning to all who were inclined that way, to for- bear doing that which may subject them to a fate which they dread so much. The judge's dictum PARTIAL INSANITY. 137 evinces an exclusive regard to the interests of so- ciety as against the wrongdoer; it ignores entirely the real nature of insanity as a disease, for which the victim is certainly not altogether responsible, and which may render him irresponsible for what he does:— " Was't Hamlet wrong'd Laertes ? Never, Hamlet: If Hamlet from himself be ta'en away, And when he's not himself does wrong Laertes, Then Hamlet does it not, Hamlet denies it. Who does it then? His madness; ift be so, Hamlet is of the faction that is wronged; His madness is poor Hamlet's enemy." Were one half the lunatic population of the country hanged, the miserable spectacle would have no serious effect upon the remaining half, and assur- edly would not deter a single insane person from do- ing murder, any more than convulsions would be pre- vented from occurring henceforth by hanging all persons who fell into convulsions. If a boy in school were wilfully to pull faces and to make strange antics, the master might justly punish him, and the punishment would probably deter other boys from following his example, but it would have no such deterrent effect upon the boy, wdiose gri- maces and antics were produced against his will by chorea; on the contrary, it would most likely ag- gravate them. The one is a proper object of pun- ishment ; the other is a sad object of compassion, whom it would be a foolish and cruel act to punish. 138 RESPONSIBILITY IN MENTAL DISEASE. So it is with the allied disease, insanity : to execute a madman is no punishment to him, and no warn- ing to other madmen, but a punishment to those who see in it, to use the words of Sir E. Coke, " a miserable spectacle, both against law, and of ex- treme inhumanity and cruelty, and which can be no example to others." And as the practice of hang- ing sheep-stealers did not prevent sheep-stealing, but, being one " of extreme inhumanity and cruel- ty," brought the law into discredit by offending the moral sense of mankind, so likewise the practice of hanging madmen will not really deter insane per- sons from doing murder, but must in the end inev- itably bring the law which sanctions it into con- tempt. The argument in favour of hanging madmen in order to deter others from crime must then be pro- nounced utterly baseless; the execution of them would be of use only if it deterred persons from going mad, which no one has asserted that it does ; but the argument that it is necessary to execute them in order to protect society would be incontro- vertible if society had no other effectual means of protecting itself. But this is not so: it has the power of protecting itself effectually, and at the same time of inflicting upon the insane wrongdoer what he assuredly regards as a heavy punishment, by shutting him up in a lunatic asylum. There need be no fear that the prospect of such a fate would be less deterrent to him than the prospect of death on the scaffold. PARTIAL INSANITY. 139 It will be observed that I have spoken of the punishment of death as one which should never be inflicted upon an insane person ; it is another ques- tion whether such a person should not be otherwise punished under any circumstances. Abolish capital punishment, and the dispute between lawyers and doctors ceases to be of practical importance. There can be no doubt that the insane inmates of asylums are to some extent deterred from doing wrong and stimulated to exercise self-control by the fear of what they may suffer in the way of loss of indul- gence or of the infliction of a closer restraint if they yield to their violent propensities. But it is equally certain that these motives can only be acted upon in a very cautious way, and that if the strain put upon them be too great, the patient is made worse and all control over him lost. It is certain too that a pa- tient who may one day be amenable to such motives may on another day, in consequence of a different phase in his disease, be altogether beyond the reach of moral influence. I do not see, therefore, how it can justly be maintained that an insane person should be subjected to any sort of punishment to the same degree as the same person, or how it can be justly argued that he should in any case be under penal rather than under medical control. I have said that the period during which insanity is coming on, when its symptoms are, as it were, premonitory of the actual disease, may be long pro- tracted in some cases. It is no easy matter at times to fix the beginning of the degeneration, so far 140 RESPONSIBILITY IN MENTAL DISEASE. back may it go in the life of the individual; for when we push close inquiries into the early histories of insane patients we may chance to discover pecul- iarities of childhood which would appear to warrant the belief that the foundations of the disease had been even then laid, and that its outbreak was the final explosion of a long train of antecedent prep- arations. This is no doubt scientifically true of a great many cases, but practically we are able to dis- tinguish symptoms which actually mark disease from peculiarities and eccentricities which have not reached the character of symptoms. Now if a per- son were to present for some length of time a class of symptoms such as are commonly the immediate forerunners of positive mania, he would most likely be described as suffering from moral insanity or from some form of partial mania. He might or he might not pass ultimately into a complete derange- ment ; but so long as he did not, he would be one of those persons whom physicians are sometimes charged with creating out of the depths of their consciousness. Let it be clearly understood that the features of some of these obscure and questioned forms of partial insanity are exactly those which are exhibited sometimes in the early stages of a genuine attack of complete insanity; these premonitory stages presenting, as it were, an abstract and brief chronicle of them. There is no unwillingness to reckon them disease when they are followed soon by an outbreak of violent mania: why should there be any hesitation to account them evidence of disease PARTIAL INSANITY. 141 when no such immediate outbreak follows to give them an unmistakable interpretation ? Not every inflammation passes into suppuration or gangrene, but it is none the less inflammation because it stops short of its worst stages. In any case, it can be hardly right to reject the testimony of a skilled ob- server with regard to an accused person's mental state, and then by hanging him before the progress of his disease can justify the skilled testimony, to cut off the opportunity of rectifying the mistake. I shall proceed then to consider the medico-legal relations of these varieties of partial insanity; for the discussion of them will raise the difficult and doubtful questions of responsibility upon which law and medicine are in conflict. All waiters on mental derangements, whatever theories they may hold with respect to their proper classification, are compelled by observation of instances to describe certain va- rieties in which there is no delusion—an insanity mainly of feeling and conduct. Thus, of the two great primary divisions of melancholia and mania, they recognise a melancholia simplex or melan- cholia without delusion, and a mania sine delirio or mania without delusion. These varieties have really an importance out of proportion to their ap- parently simply character, for it is in them that dangerous impulses to homicide or suicide or other destructive acts are especially apt to occur; and it is when a person labouring under one of them perpe- trates some act of violence, before he has developed any delusion or incoherence of thought, that an 142 RESPONSIBILITY IN MENTAL DISEASE. angry conflict of opinion rages through the country. Now as the main difference between melancholia without delusion and mania without delusion is, that there is marked mental depression in the former and no notable depression in the latter, it will be most convenient for our present purpose to consider them together under the common name of Affective in- sanity—that is, Insanity without delusion, or In- sanity of feeling and action. The two chief sub- divisions of this class (which I propose to make) are Impulsive insanity and Moral insanity* I do not forget that the lawyers have declared delusion to be the test of insanity, but that is a doc- trine which, in common with other physicians who know anything of insanity, I do not hesitate to pro- nounce erroneous. In the first place, there may be insanity without delusion, as I have already said; and, in the second place, when delusion is present its value as a symptom of insanity may vary much. Some delusions appear to be little more than un- founded and extreme suspicions; jealousy on the part of husband or wife, religious apprehensions, the delusion that friends and children are unkind or actually conspiring to injure the individual, are cer- tainly not by themselves proofs of insanity, although they may become weighty evidence when associated * In adopting these divisions 1 would guard against being supposed to propound them as a classification of insanity. In- sane impulses and moral alienation are met with in various forms of mental disease. I use the divisions as a convenient method of raising and discussing the medico-legal questions. PARTIAL INSANITY. 143 with other symptoms of disease which give them their true interpretation. The absence of delusion will not disprove, nor will the presence of delusion always prove, insanity. 1. Impulsive Insanity. It will be a hard matter for those who have not lived among the insane and so become familiar with their ways and feelings to be persuaded, if, without such experience, they ever can, that a man may be mad and yet be free from delusion and exhibit no marked derangement of intelligence. Nevertheless it is a fact that in a certain state of mental disease a morbid impulse may take such despotic possession of the patient as to drive him, in spite of reason and against his will, to a desperate act of suicide or homicide; like the demoniac of old into whom the unclean spirit entered, he is possessed by a power which forces him to a deed of which he has the ut- most dread and horror; and his appeal sometimes to the physician whom he consults in his sore agony, when overwhelmed with a despair of continuing to wrestle successfully with his horrible temptation, is beyond measure sad and pathetic. Suicidal Insanity.—The most anxious cases with which those have to do who are engaged in the care and treatment of the insane, are unquestionably those in which there is a persistent suicidal impulse, it may be without appreciable disorder of the intel- lect. The patient is quite aware of his morbid state, deplores it, struggles against the horrible temptation, 144 RESPONSIBILITY IN MENTAL DISEASE. but in the end, unless very closely watched, is hur- ried into suicide by it. Of course such a person is depressed because of his state, feels no interest in his usual pursuits, and cannot follow them ; every- thing is swallowed up in the absorbing misery of his temptation ; but he is under no delusion, his intel- lect is clear; he can reason about his condition as well as any one else can; his knowledge of right and wrong in regard to the act is most keen. Nev- es o ertheless his intellect is at times so completely the slave of his morbid impulse that it is constrained to watch for opportunities and to devise means to carry it into effect. No one who had not seen it could believe what ingenuity there may be in planning and what determination in executing a deed which all the while is reprobated as most wicked. Many examples of this form of derangement might be quoted from writers on insanity ; but I shall content myself with mentioning two cases which came under my own observation. A married lady, thirty-one years of age, sprung from a family in which there was much insanity, was, a few weeks after her confinement, seized with a strong and persistent suicidal impulse, without delusion or disorder of the intellect. After some weeks of zealous attention and anxious care from her relatives, who were all most unwilling to send her from home, it was found absolutely necessary to send her to an asylum ; so frequent, so cunningly devised, so determined were her suicidal attempts. On admission she was very wretched because of the PARTIAL INSANITY. 145 frightful impulse with which she was possessed, and often wept bitterly, deploring the great grief and trouble which she caused to her friends. She was quite rational, even in her horror and reprobation of the morbid propensity; all the fault that could be found with her intellect was that it was enlisted in its service. Nevertheless, her attempts at suicide were unceasing. At times she would seem quite cheerful, so as to throw her attendants off their guard, and then would make with quick and sudden energy a precontrived attempt. On one occasion she secretly tore her night-dress into strips while in bed, and was detected in the attempt to strangle herself with them. For some time she endeavoured to starve herself to death by refusing all food, and it was necessary to feed her with the stomach-pump. The anxiety which she caused was almost intoler- able, but no one could grieve more over her miser- able state than she did herself. After she had been in the asylum for four months, there appeared to be a slow and steady improvement, and it was generally thought, as it was devoutly hoped, that she would make no more attempts at self-destruction. Watch- fulness was somewhat relaxed, when one night she suddenly escaped out of a door which had been carelessly left unlocked, climbed over a high garden wall with surprising agility, and ran off to a reser- voir of water into which she threw herself headlong. She was rescued before life was quite extinct; and after this all but successful attempt she never made another, but gradually regained her cheerfulness 146 RESPONSIBILITY IN MENTAL DISEASE. and love of life, and finally left the establishment in her right mind. In face of this example of uncon- trollable morbid impulse, with clear intellect and keen moral sense, wdiat becomes of the legal cri- terion of responsibility ? A gentleman of middle age, and of ample means, happily married, but sprung from a family in which other members had been insane, and who, before marriage, had lived a dissipated life, and was now suffering from the enervating effects of his excesses, became the victim of desperate suicidal insanity. He had once before had a similar attack from which he had recovered in a few months. On this occa- sion he was terribly distressed and depressed by rea- son of the impulse to destroy himself—there was no other cause of depression—but at the same time de- clared calmly that he must do it, and that he should have done it before this if he had not been a cow- ard. To all attempts to comfort him by the assur- ance that it would pass away, as it had done on a former occasion, he smiled incredulously, repeating the declaration that he must do it. He had been recommended to travel for change of scene, but as he had attempted to throw himself overboard while at sea, he was brought back home and placed under special care. He continued, however, in the same hopeless and despairing state of mind, protesting calmly that he must do it, that he was disgraced and dared not look people in the face because of his cowardice in not doing it; and all this so quietly that it was hardly possible to think that he really PARTIAL INSANITY. 147 meant what he said. Nevertheless, one morning he eluded the vigilance of his attendant, ran off as fast as he could across hedges and ditches, closely but vainly pursued, to a railway, clambered up a high embankment, and deliberately laid himself down across the rails in front of a passing train, which killed him on the spot. Except that this un- fortunate gentleman had the insane suicidal impulse, and thought himself a disgraced man, who never could hold up his head again because of his coward- ice, he was in all respects apparently sane. These two instances, which might be paralleled by many similar ones, will serve to show how limited the mental derangement may seem to be in what we call suicidal mania or monomania. I say seem to be because there is reason to believe, as will be seen subsequently, that there is sometimes really more derangement in this monomania, and in other forms of monomania, than actually appears on the surface. Obviously the whole energy of the mind was ab- sorbed in the morbid function, no interest in the affairs of life was possible, and there was no power left to discharge its duties; the morbid idea domi- nated thought, feeling, and eventually action. In both cases it will be noted again that there was a strong hereditary predisposition to insanity, although it did not appear that it was a special predisposition to suicidal insanity. The patients, however, had the insane neurosis, which displayed its morbid energy in a convulsive idea, not otherwise than as the epi- leptic neurosis, to which it is closely allied, displays 148 RESPONSIBILITY IN MENTAL DISEASE. its morbid energy in convulsive movement. Look- ing at their mental state from a strictly pathological point of view, it is entirely consistent with experi- ence ; for as the function of the motor centres is movement, so the function of the supreme nerve- centres is thought, and as a morbid state of the mo- tor centres occasions convulsion of movements, sO, in like manner, a morbid state of the mind-centres occasions what, for want of a more appropriate term, may be called convulsion of idea. And as the will cannot restrain a convulsive movement, of which the patient may all the while be conscious, so the will cannot always restrain, however much it may strive to do so, a morbid idea which has reached a convulsive activity, although there may be all the while a clear consciousness of its morbid nature. It is notable how strongly hereditary this sui- cidal insanity often is, and how desperate are its manifestations under such circumstances, even when there is no other sign of mental alienation. A gen- tleman of great intellectual power, occupying a high position in his profession, and endowed with re- markable energy, consulted me on three or four occasions on account of sleeplessness, depression, and unusual mental worry about certain matters of business when there was not adequate occasion for it. He was perfectly clear in his intellect, under- stood thoroughly all his affairs, and talked as sensi- bly as any one else could have done of his own con- dition. The idea of suicide had arisen at times in his mind, but he had resisted it as contrary to his PARTIAL INSANITY. 149 religious principles and to his judgment. If any one had asked me if I thought him a likely man to commit suicide, I should have replied that his strength of character and his intellectual power were so great as to render it improbable. Never- theless he left his house one day, hastened to one of the bridges over the Thames, and, after walking backwards and forwards over it several times, threw himself from it into the river. He was rescued, did not suffer at all from the consequences of his des- perate leap, and finally recovered his health and spirits. His mother had laboured under suicidal propensities, and during the last years of her life it had been necessary to fasten down the windows of her house, in order to prevent her from throwing herself out of one of them. His brother, a sensible and successful man of business, would never travel by train if he could help it, and never on any occa- sion by express train, because of a strong impulse which he felt to throw himself out of the carriage* * In illustration of the known desperate character of suicidal mania and of its hereditary causation, I may mention the case of an accomplished young lady who was under Dr. Conolly's care in his house, and regarding whom the final note is as fol- lows :_«Seems to be almost constantly meditating suicide. After appearing cheerful for a time she will urgently entreat the attendants to let her have a knife. . . . Long observation of her, and knowledge of this peculiar tendency having shown itself in her mother and in two or three other relatives, make her suicide so much to be apprehended that her friends are recommended to remove her to an asylum where there are more patients, and where the arrangements are more adapted 11 150 RESPONSIBILITY IN MENTAL DISEASE. The suicidal propensity is inherited like the tricks of movements which run in families : it may be latent or dormant while the individual is strong and healthy, and all things are going well with him; but if his nervous energy be exhausted, and the tone of his system depressed by any cause, then it springs into activity, and may display itself in a convulsive energy. In this state it seems as if it were inde- pendent of the operations of the mind, which is otherwise rational, as if it were a demon that had taken possession of the man, and ruled him in spite of reason and will. Suggestion has often a great influence in exciting it into activity: the accounts of suicides in the newspapers are either avoided anxiously as being too powerfully suggestive, or they exert a singular attraction, and are perused with a morbid interest; the idea becomes familiar to the mind, the horror of it wears off, and when there is melancholic depression it presents itself in a vivid form, and is readily carried into effect. The suicide of a relative or friend has a still more pow- erful infective effect. In the event of a person af- flicted with this form of mental disease committing suicide, no one would question his insanity; but there is not the same willingness to recognise dis- ease when the morbid impulse is not suicidal, but homicidal. Homicidal Insanity.—Nevertheless, it is certain for cases of unusual difficulty or danger." This was done; and three months afterwards she put an end to her life by hanging. PARTIAL INSANITY. 151 that there is an exactly similar form of homicidal mania or monomania in which the patient is pos- sessed with an impulse to kill somebody, is infinitely miserable in consequence, and yet exhibits no other mental derangement. We owe the description of this form of madness—manie sans delire, as he calls it,—to Pinel,* who, believing at first that insanity was inseparable from delirium or delusion, on prose- cuting his researches " was not a little surprised to find many madmen who at no period gave evidence of any lesion of the understanding, but who were under the dominion of instinctive and abstract fury, as if the affective faculties had alone sustained in- jury." He relates the following case in exempli- fication of these remarks :— " A man who had previously followed a mechan- ical occupation, but was afterwards confined at Bice- tre, experienced, at regular intervals, fits of rage, ushered in by the following symptoms. At first he experienced a sensation of burning heat in the bowels, with an intense thirst and obstinate con- stipation ; this sense of heat spread by degrees * But long before him Ettmuller (Prox. lib. ii., cap. 4. Op. torn, iii., p. 368) had spoken of it as melancholia sine delirio, a state of mental disorder in which there was recta ratio sine delirio. He even cites two observations of Plater, one of which refers to a mother who had often been tormented with the desire of killing her child; the other, to a woman who was tor- mented with a desire to utter blasphemies. Both succeeded in resisting their morbid propensities. See De la Polie cons, dans ses Rapports avec les Questions Medico-judiciaires, par C. C. H. Marc, vol. i., p. 226, 152 RESPONSIBILITY IN MENTAL DISEASE. over the breast, neck, and face, with a bright colour; sometimes it became still more intense, and produced violent and frequent pulsations in the arteries of those parts, as if they were going to burst; at last the nervous affection reached the brain, and then the patient was seized with an irre- sistible, sanguinary propensity ; and if he could lay hold of any sharp instrument, he was ready to sac- rifice the first person that came in his way. In other respects he enjoyed the free exercise of his reason ; even during the fits he replied directly to questions put to him, and showed no kind of in- coherence in his ideas, no sign of delirium ; he even felt deeply all the horror of his situation, and was often penetrated with remorse, as if he was respon- sible for this mad propensity. Before his confine- ment at Bicetre a fit of madness seized him in his own house ; he immediately warned his wife of it, to whom he was much attached; and he had only time to cry out to her to run away lest he should put her to a violent death. At Bicetre there ap- peared the same fits of periodical fury, the same mechanical propensity to commit atrocious actions, directed very often against the inspector, whose mildness and compassion he was continually prais- ing. This internal combat between a sane reason in opposition to sanguinary cruelty reduced him to the brink of despair, and he often endeavoured to ter- minate by death the insupportable struggle. One day he contrived to get possession of the cutting- knife of the shoemaker of the hospital, and inflicted PARTIAL INSANITY. 153 a severe wound upon himself in the right side of his chest and arm, which was followed by violent haemorrhage. Strict seclusion and a strait-waist- coat prevented the completion of the suicide." At one period of his career, Esquirol was dis- posed to think that most, if not all, the cases which Pinel had described under the name of mania with- out delirium—manie sans delire, were really exam- ples of ordinary monomania or melancholia, charac- terised by fixed and exclusive delusion ; that there was in fact actual disorder of intelligence. Such was the opinion which he expressed in his article on mania in the Dictionnaire des Sciences Medi- cates, in 1818, but his subsequent observations compelled him to abandon it, and to declare that although some insane persons committed homicide in consequence of delusions, hallucinations or illu- sions, there were unquestionably others who were driven by an instinctive impulse, a blind instan- taneous impulse, independent of the will, and who acted without passion, without delusion, without motive. To this condition, the monomanie sans delire of Pinel, he gave the name of monomanie in- stinctive, distinguishing it, in the first place, from true monomania, monomanie intellectuelle, in which there was delusion, and, secondly, from monomanie affec- tive or moral insanity. It is rather unfortunate that the word monomania has thus come to be used in two senses—first, as denoting fixed delusion, and, second- ly, as denoting the form of mental derangement in which, without delusion, the patient is possessed 154 RESPONSIBILITY IN MENTAL DISEASE. with an insane and perhaps irresistible impulse to homicide, suicide, or other act of violence. To avoid the confusion thereby occasioned, I shall speak of the latter under the name of impulsive insanity; avoiding also the word instinctive, that it may not be thought I attribute to man a natural instinct to do murder. There are very few persons engaged in the study and treatment of insanity who have not, like Esquirol, begun by doubting the existence of cases of real impulsive insanity; there are none who, after having had a large enough experience, have not, like him, been compelled to abandon their doubts. To those who judge by the experi- ence of a sane self-consciousness, and so prejudge the facts, it seems an inconceivable state of mind, or, at any rate, it seems inconceivable that a person in such a state of mind should not have the power to control the insane impulse; to those who form their conclusions from observation and experience of the facts of the disease, and so interpret them fairly, no doubt of its existence is finally possible. Many examples have been recorded by writers on insanity, but it will be sufficient for my purpose to mention the following cases :— Not long ago a gentleman, aged fifty years, of great animal vigour and enormous muscular develop- ment, who had lived a very energetic life, and vis- ited in the course of his work most parts of the world, but had now for some years retired from active employment, consulted me because of a dis- PARTIAL INSANITY. 155 tressing homicidal impulse with which he was tormented. It was so continually present in his mind, and at times so strong, that he was com- pelled to live apart from his family, wandering from hotel to hotel, lest he should become a murderer; it varied considerably in intensity, but never entirely disappeared; when in his best state it was an idea which continually occupied his thoughts, without an actual inclination to carry it into effect—a homicidal idea rather than a homicidal impulse ; but from time to time it ac- quired a brief paroxysmal activity, the paroxysms being accompanied by a rush of blood to the head, a sense of fulness and confusion there, a horrible feeling of helplessness, and by violent trembling of the body, which was covered with a profuse sweat. They passed off in a flood of tears, and were followed by exliaustion. The attacks often seized him in the night, when he jumped out of bed in an agon}7 of fear, shuddering so violently that the room shook, while the perspiration poured down his body. Such was his description of his miserable state, the truthfulness of which no one who listened to his story could have had the heart to doubt, for he burst into tears as he told it and wept bitterly. He was manifestly a person of great decision and energy of character, and he did not ex- hibit any further evidence of intellectual derange- ment unless it were a morbid tendency to a ground- less suspicion and distrust. Though accustomed to exercise great control over himself in some respects, 156 RESPONSIBILITY IN MENTAL DISEASE. in one respect he signally failed to do so ; for he was addicted to a vice well fitted to damage his nervous system, and in some measure to account for his pitiable state.* Many cases of homicidal insanity have been col- lected and recorded by Marc, in some of which the impulse to kill was not accompanied by any other appreciable disorder of mind. The following is a well-known and often-quoted example :— " In a respectable house in Germany, the mis- tress of the house, on her return home one day, found her servant, against whom there had never been a complaint, in a state of great agitation; she wished to speak with her mistress alone, when she * In my work on the Physiology and Pathology of Mind (2nd Ed., p. 348), I have related the following case : " An old lady, aged seventy-two, several members of whose family had been insane, was afflicted with recurring paroxysms of convul- sive excitement, in which she always made desperate attempts to strangle her daughter, who was very kind and attentive to her, and to whom she was much attached. Usually she sat quiet, depressed, and moaning because of her condition, and was ap- parently so feeble as scarcely to be able to move. Suddenly she would start up in great excitement, and, shrieking out that she must do it, make -a rush upon her daughter that she might strangle her. During the paroxysm she was so strong, and writhed so actively, that one person could hardly hold her; but after a few minutes of struggling she sank down quite ex- hausted, and, panting for breath, would exclaim,' There, there ! I told you ; you would not believe how bad I was.' No one could detect any delusion in her mind ; the paroxysm had all the appearance of a mental convulsion. It was because of her horrible propensity to an act of which she felt the greatest horror that she was so wretched." PARTIAL INSANITY. 157 threw herself down on her knees, and begged per- mission to leave the house. Her mistress, astonished at such a request, desired to know the reason, and thereupon learnt that whenever the anhappy serv- ant undressed the lady's child, and was struck with the whiteness of its flesh, she felt an almost irre- sistible desire to rip it up. She feared that she should yield to the impulse, and begged therefore to leave the house. This event," says Marc, " hap- pened twenty years since in the family of the illus- trious Baron A. Humboldt, who has permitted me to quote his testimony." * Other examples of a similar kind are quoted by Marc:— " A young lady whom I have examined in one of the asylums of the capital, experienced homicidal desires for which she could not assign any motives. She was not irrational on any point, and on each occasion when she felt the fatal propensity recur and mount up, she burst into a flood of tears, and prayed that she might be put in the straitwaistcoat, which she kept on patiently until the attack, which sometimes lasted several days, had passed off." f "Mr. R., a distinguished chemist and a poet, of a naturally mild and social disposition, placed him- self under restraint in one of the maisons de sante of the Faubourg St. Antoine. Tormented with a homi- cidal impulse, he prostrated himself at the foot of the altar, and implored the Divine assistance to de- * Vol. ii., p. 101. f Ibid-. P- 103- 158 RESPONSIBILITY IN MENTAL DISEASE. liver him from the atrocious propensity, of the cause of which he could give no account. When he felt himself likely to yield to the violence of it, he hastened to the head of the establishment, and requested him to tie his thumbs together with a ribbon. This slight ligature was sufficient to calm the unhappy K., who subsequently endeavoured to kill one of his friends, and finally perished in a fit of maniacal fury." "A woman, never insane enough for confine- ment, told me," says Dr. Conolly,* " that she some- times lay awake in the night looking at her husband, and thinking how easily she might kill him with the broom-handle; and that she awoke him that his talking to her might drive these thoughts out of her head." Esquirol relates the following case among other cases more or less like it:—" A country gentleman, about forty-five years of age, in easy circumstances, and enjoying good health, came to consult me, ac- companied by a young medical man. He gave me the following details :—There was no indication of the slightest disorder of reason in him; he an- swered with precision all my questions, which were numerous. He had read the indictment of Henri- ette Cornier, without, however, having given much attention to it. Nevertheless in the night he awoke suddenly with the thought of killing his wife, who was lying by his side. He left his bed, and walked * Croonian Lectures, p. 92. PARTIAL INSANITY. 159 up and down the room for an hour, after which, feeling no more disquietude, he lay down and went to sleep; three weeks afterwards the same idea occurred on three occasions, always in the night. During the day he took plenty of exercise, occu- pied himself with his numerous affairs, and had only the remembrance of what he had felt in the night. He had been married twenty years, had always enjoyed good health, was in prosperous cir- cumstances, and had never had the least disagree- ment with his wife, to whom he was attached. It is an idea which seizes upon him during his sleep. He is sad and troubled about his condition, has left his wife from the fear that he might yield to his propensity, and is very willing to do everything to deliver himself from his dreadful affliction." * These cases, to which many more of a like na- ture might be added, are of great psychological in- terest, for which reason I have quoted them in the words of their narrators. Whatever difference of opinion there may be concerning the interpretation of them, no one can question the competency of the observers or the accuracy of their description of the facts. It may no doubt be fairly argued that a per- son is not to be counted insane simply because the idea of killing another person comes into his mind, more especially when he recognises its atrocity and abhors it; but when he cannot dismiss it from his thoughts, although he feels keenly its enormity; * Esquirol, Des Maladies Mentales, vol. ii., p. 830. 160 RESPONSIBILITY IN MENTAL DISEASE. when it is directed against some one against whom he has not the least animosity, perhaps against some one near and dear to him; when he is truly pos- sessed by it, so that he is in an agony of fear lest he should yield to its influence, in spite of reason and against his will, and flees from temptation; when he is weary of his life because of its malign power over him, and perhaps commits suicide that he may not commit homicide ;—then surely it must be ac- knowledged that his mental functions are not sound, but diseased. He certainly does all a man can do to prove that he is not an impostor when he kills himself to prevent a worse consummation, or when, as one of these patients did, he subsequently dies raving mad. The fact that he does successfully re- sist the insane impulse by calling up ideas to coun- teract it, or by getting out of the way of temptation, is assuredly not, as many persons think, and some argue, a proof that he might continue to do so on all occasions. The understanding and the will, like all other organic functions, are subject to fluctua- tions, and, when disease of mind exists, to very great fluctuations: whether the will shall overcome the morbid impulse, or be overcome by it in the end, is really a question of the degree of the disease; if this increase, as it may well do, from temporary bodily disorder or from other causes, the idea ac- quires a fatal predominance ; it is no longer an idea, the relations of which the mind can contemplate, but a violent impulse, which, swallowingup reflection and will, irresistibly utters itself in convulsive action. PARTIAL INSANITY. 161 Let us briefly consider then how the matter stands. By the unanimous testimony of all those who have made insanity a practical study it is agreed that instances of irresistible homicidal impulse do occur ; that this is a positive fact of observation, be the explanation of it what it may. The assertion of the existence of such a form of mental disease is opposed, not to common prejudices only, but to the conclusions which any person would be likely to form a priori from a metaphysical philosophy of mind. Public writers and lawyers, therefore, natu- rally jealous of the application of the doctrine to excuse crime, have rejected and reviled it as a dan- gerous and absurd medical crochet; having been probably the more moved to do so because they per- ceive that, if it be admitted, they will be impotent, by reason of their ignorance of insanity, to put a proper check upon its application. They have acted partly then out of a natural jealousy of its abuse, but partly also, I think, out of bad philosophy; con- cluding from the observations of self-consciousness in a sane mind as to what passes in an insane mind, they have judged the insane with an unjust judg- ment. They would have done better if they had founded their opinions of the workings of an un- sound mind upon their experience of what passes in a 'sound mind when dreaming, for there is a large measure of truth in the saying that a madman dreams with his eyes open. Like the dreamer, he is gov- erned by the strangest associations of ideas, and feels himself irresistibly impelled to do what his reason 162 RESPONSIBILITY IN MENTAL DISEASE. disapproves and his moral feeling abhors, aghast at himself the while. The medical psychologist, who studies mental function by the physiological method, who judges of the functions of the supreme nerve-centres in man by aid of the generalisations which he has formed regarding their functions in animals, where they have not attained so great a development, and by aid also of the generalisations which he has formed concerning the functions of the lower nerve- centres in man, does not experience the same diffi- culty in realising the probable state of mind in im- pulsive insanity, and in conceiving an explanation of it. Placing insanity in the same category as a nerv- ous disease with chorea, which has not inaptly been called an insanity of the muscles, he perceives that just as a deranged state of the motor centres destroys co-ordination of movements and occasions spasmodic or convulsive muscular action, so a deranged state of the mind-centres destroys the healthy co-ordina- tion of ideas, and occasions a spasmodic or convul- sive mental action. In the one case the man is un- able to perform his movements correctly, in the other case he is unable to perform his ideas correctly —in both cases they play him evil tricks against his will, though within his consciousness. Thus we reconcile the unanimous experience of skilled ob- servers of impulsive insanity with the generalisa- tions of a positive mental science, which might, in truth, enable us to predicate, apart from experi- PARTIAL INSANITY. 163 ence, that such a form of disease must sometimes occur. In some of these cases of impulsive insanity little or no mental derangement, apart from the morbid idea or impulse, has been noticed. This is expressly stated and forcibly insisted upon by their narrators; but in most cases I believe it will be found, on an intimate knowledge of the person's feelings and do- ings, that there is more derangement than appears on the surface. His whole mental tone is more or less affected, so that his feelings are blunted or changed, the natural interests of life extinguished, and his judgments of his relations to others and of their relations to him somewhat impaired; he is apt to become suspicious of and hostile to those who have been his nearest friends and acquaintances, and may finally get delusions concerning them. Our beliefs, sane or insane, are not the results of reason, but have their roots in that unconscious part of our nature, of the state of which the feelings are the indices. It is from the feelings, too, that the impulses to action spring, the function of the intellect, like that of the steersman at the ship's helm, being regulative, and the insane impulse of the homicidal patient is the deranged offspring of a deranged affective life. It is surprising sometimes how sane a person may appear who all the while has a greater derange- ment than was ever suspected, until something hap- pens to elicit the evidence of it. When he with- draws from his accustomed occupations, and lives a 164 RESPONSIBILITY IN MENTAL DISEASE. gloomy life of retirement, absorbed in himself and in his sufferings, there is no provocation to more general manifestations of insanity. Let the strain of active life, however, be put upon him ; let him go about his affairs in the world as other men do, be called upon for judgment and action in the rela- tions of life, and, above all, let the various feelings which it is necessary to subdue and control in inter- course with men be brought into play ; it will then oftentimes be made plain that the patent morbid symptom is the result of a fundamental derange- ment which requires only circumstances to bring it forth. Perhaps it has been in some degree owing to the way in which this deep perversion of feeling, this affective derangement, has been overlooked or made of no account, attention having been attracted exclusively to the morbid idea or act, that there has been so great an aversion from the doctrine of im- pulsive insanity. And yet its impulsive character is of the very essence of insanity ; for in all forms of the disease paroxysms of impulsive violence are common features; without assignable motive insane patients suddenly tear their clothes, break windows or crockery, attack other patients, do great injury to themselves ; they exhibit unaccountable impulses to walk, to run, to set fire to buildings, to steal, to utter blasphemous or obscene words; wherefore if there be one thing which a large experience of them teaches, it is how impossible it is to foreknow the impulses which may suddenly arise in their minds and to trust them from hour to hour. The PARTIAL INSANITY. 165 paroxysmal impulse of homicidal insanity is not singular in its nature; it is singular only in being the prominent or apparently single symptom of the disease. When there is disease of brain which produces derangement of mind, it is of the nature of the dis- order to express itself in all sorts of perverted appe- tites, instincts, and desires, as well as in perverted ideas. In all large asylums there are inmates who display the most depraved appetites; some who, if not carefully watched, eat with apparent relish grass, frogs, worms, and even garbage of the most offensive kind; others who exhibit depraved and exaggerated manifestations of the sexual instinct; others in whom there is a perversion or loss of the instinctive love of offspring, so that a mother will neglect, hate, or actually destroy her own child. Even the strong self-conservative instinct, which is at the foundation of love of life, may be perverted, so that an insane person will mutilate himself in the most horrible manner, sometimes apparently from a mere love of mutilation which he does not seem to feel to be painful. When an organism is out of har- mony with the circumstances in which it should live, by reason of internal derangement, its tenden- cies are to self-extinction, which it would often reach quickly, if it were not carefully guarded from the destructive action of its perverted affinities. Persistent suicidal impulse marks the replacement of the self-conservative by a similar self-destructive impulse. The impulses to burn, to steal, to kill, are 12 166 RESPONSIBILITY IN MENTAL DISEASE. in like manner occasional symptoms of deranged nerve-element, and have nothing in their nature more exceptional or surprising than other insane impulses. It is not our business, as it is not in our power, to explain psychologically the origin and nature of any of these depraved instincts ; it is suf- ficient to establish their existence as facts of obser- vation, and to set forth the pathological conditions under which they are produced: they are facts of pathology, which should be observed and classified like other phenomena of disease; they certainly ought not to be repudiated because the acutest psy- chological analysis is incompetent to explain their origin. The explanation, when it comes, will come not from the mental but from the physical side— from the study of the neurosis, not from the analy- sis of the psychosis. Now if it were possible in all cases of homicidal insanity to point to evidence of derangement before the outbreak, there would be infinitely less disin- clination to admit the existence of disease. In most of the genuine cases I doubt not that this can and should be done. But if we go on to declare that there cannot be a case of true homicidal insanity save where antecedent symptoms of disease have been observed, we are certainly going farther than we are warranted either by experience or by a priori considerations. For, in the first place, au- thors of weight and authority maintain positively the existence of such cases—cases where, to use Griesinger's words, " individuals, hitherto perfectly PARTIAL INSANITY. 16? sane and in the full possession of their intellects, are suddenly, and without any assignable cause, seized with the most anxious and painful emotions, and with a homicidal impulse as inexplicable to themselves as to others." In the second place, other diseases as well as other forms of insanity sometimes declare themselves in quite a sudden man- ner : a man's first epileptic fit does not give any in- telligible warning of its coming; an acute mania sometimes bursts out more suddenly than a thunder- storm in a summer's sky; and even valvular disease of the heart, aortic or mitral imperfection, may first become known by a sudden exertion. No doubt in such cases there has been previous weakness of some sort, not recognisable perhaps until the strain has come which has discovered the flaw; there may have been vague threatenings which have been overlooked or misunderstood. The beginnings of disease are, as a rule, latent or obscure; modern medicine is setting itself patiently to work to trace them out; and now-a-days physicians would hardly be brought to credit the occurrence of acute idio- pathic disease in a healthy subject. Let it be borne well in mind, then, that there are latent tenden- cies to insanity which may not discover the least overt evidence of their existence except under the strain of a great calamity or of some bodily dis- order, and that the outbreak of actual disease may then be the first positive symptom of unsoundness; the brain in respect of its mental functions differing not in this regard from itself in respect of its other 108 RESPONSIBILITY. IN MENTAL DISEASE. functions, nor from other organs of the body in respect of their functions. I shall now, then, proceed to point out what I conceive to be the most important conditions which are precedent of an outbreak of insane homicidal impulse. These are the insane neurosis and the epileptic neurosis, in both which the tendency is to convulsive action. It is in strict accordance with the view taken of homicidal impulse as a convulsive idea springing from a morbid condition of nerve- element, and comparable with a convulsive move- ment, that it should most often occur where there is hereditary predisposition to insanity; it may be that in some cases there is not, but there can be no doubt that in the majority of cases there is, such a neuro- pathic state. It is in accordance again with experi- ence that when this neurosis exists, and when the circumstances of life or physiological and pathologi- cal conditions put a great stress upon the nervous organization, an outbreak of homicidal impulse should in some instances be the first overt evidence of insanity. Among such physiological and patho- logical conditions we reckon the development of puberty with the revolution which takes place then in the mental and bodily economy, pregnancy and the puerperal state, the change of life, irregularities of functions in women, the effects of excessive drink- ing and of other injurious vice. Not one of these conditions but has occasioned an outbreak of insan- ity in a person predisposed to the disease; not one of these conditions, furthermore, but has, as the re- PARTIAL INSANITY. 169 corded cases show, occasioned an outbreak of homi- cidal insanity. The cases of homicidal insanity which have oc- curred under these conditions may be divided into two classes: the first consisting of those in which there has been some defect of intellect, more or less imbecility of mind; the second consisting of those cases in which, without any manifest intellectual de- fect, there has been an insane temperament. As an example of the first class I may quote the case of Burton, who was tried at the Maidstone Lent As- sizes, in 1863, for murder. It was very simple and very shocking. The prisoner was a youth of eight- een years of age; his mother had been twice in a lunatic asylum, having been desponding, and having attempted suicide; his brother was of weak intel- lect, silly and peculiar. He himself was of low mental organization, and the person to whom he was apprenticed and others gave evidence that he was always strange, and not like other boys; he " had a very vacant look, and when told to do any- thing, would often run about looking up to the sky as if he were a maniac;" so that the indentures were cancelled. The prisoner said that he had felt " an impulse to kill some one;" that he sharpened his knife for the purpose, and went out to find some one whom he might kill; that he followed a boy, who was the first person he saw, to a convenient place ; that he knocked him down, stuck him in the neck and throat, knelt upon his belly, grasped him by the neck, and squeezed till the blood came 170 RESPONSIBILITY IN MENTAL DISEASE. from his nose and mouth, and then trampled upon his face and neck until he was dead. He then washed his hands, and went quietly to a job which he had obtained. He knew the boy whom he had murdered, and had no ill-feeling against him, " only I had made up my mind to murder somebody: " he did it because he wished to be hanged. His coun- sel argued that this vehement desire to be hanged was the strongest proof of insanity; the counsel for the prosecution, on the other hand, urged that the fact of his having done murder in order to be hanged, showed clearly that he knew quite well the consequences of his act, and was therefore crimi- nally responsible. He was found guilty; and Mr. Justice Wightman, in passing sentence, informed him that he had been " found guilty of a more bar- barous and inhuman murder than any which had come under my cognisance during a judicial experi- ence of upwards of twenty years. It is stated," the judge went on to say, " that you laboured under a morbid desire to die by the hands of justice, and that for this purpose you committed the murder. This morbid desire to part with your own life can hardly be called a delusion ; and, indeed, the con- sciousness on your part that you could effect your purpose by designedly depriving another of life, shows that you were perfectly able to understand the nature and consequences of the act which you were committing, and that you knew it was a crime for which by law the penalty was capital. This was, in truth, a further, and I may say a deeper, PARTIAL INSANITY. 171 aggravation of the crime!" When sentence of death had been passed, the prisoner, who during the trial had been the least concerned person in court, said, with a smile, " Thank you, my lord," and went down from the dock, " followed by an audible mur- mur, and almost a cry of horror from a densely crowded audience." He was in due course exe- cuted; the terrible example having been thought necessary in order to deter others from doing mur- der out of a morbid desire to indulge in the gratifi- cation of being hanged. There are certain circumstances, however, which might well make us pause before accepting the theory of extreme depravity, which was so satisfac- tory to the judge's mind in Burton's case. His hereditary antecedents, his low mental organization, the previous history of incapacity which made it necessary to cancel the indentures, the insane mo- tive from which he committed the murder, the desperate way in which it was done, or, so to speak, overdone, his conduct immediately afterwards, the readiness with which he told all about it, his indif- ferent behaviour during the trial, and his satisfac- tion with the sentence—all indicated a state of mind which the fear of capital punishment was not likely to have any good effect upon. There was no need to found a diagnosis of insanity upon the act itself, peculiar as was its character, nor upon the motive of it, insane as that was; through a chain of circum- stances the course of the hereditary disease down- wards to its desperate evolution was traceable. Cer- 172 RESPONSIBILITY IN MENTAL DISEASE. tainly, were it necessary, many cases of acquittal on the ground of insanity might be quoted, in which the evidence of mental derangement was far less than it was in this sad case. The argument drawn from his knowledge of the nature and consequences of the act which was used by the judge to demonstrate his responsibility, though in strict accordance with English judge- made law, can hardly be considered to answer all the difficulties of the case; for what power of choice between right and wrong, and of will to do the one and resist the other, could be justly attributed to one to whom the prospect of the greatest punishment which human justice can inflict, so far from proving deterrent from crime, was actually the incentive to do it ? Well might the judge, who, in his sentence of death, " could not trust himself to dwell upon the shocking details," be aghast after a judicial experi- ence of twenty years at this new revelation of the depravity of human nature. Had he considered the matter a little more deeply, he might perhaps have seen reason to question whether the boy's state of mind rendered it possible for him to form such an estimate of the moral character of his act as even the law required. After all, the criminal law sup- poses some knowledge of moral principles, in those whom it regards as fit subjects for punishment; its aim being, I presume, to treat criminals not simply as vermin to be destroyed, but as moral beings to be punished. If the example of Burton's execution was to have a deterrent effect, this effect ought to PARTIAL INSANITY. 173 have been specially exerted upon those who were in a similar state of mind and troubled with similar morbid desires; and yet it is plain that on such per- sons it would have had a directly opposite effect, and would have stimulated them to do murder, by strengthening the insane motive which instigated it —the desire to be hanged. This case may be taken as representative of a class. It must be remembered only that the natural defect of intellect may be great or little, and that the insane impulse may not always be homicidal. In some the impulse is suicidal; they kill them- selves, without any apparent, or, at any rate, with- out an apparently sufficient motive, and perhaps at a much earlier age than it is customary for suicide to be done. Others yield to the destructive im- pulse to set fire to houses, or bams, or other prop- erty, without having any ill-feeling against the per- son whom they thus injure, or any purpose to serve by what they do. There can be no doubt that the act of violence, whatever it be, in these cases is sometimes suggested by the sensational reports of similar deeds in the newspapers. The example is contagious; the idea fastens upon the weak or de- pressed mind, and becomes a sort of fate against which it is unable to contend. As an example of the second class of cases, in which an insane homicidal impulse springs up sud- denly without external provocation in the mind of a person who has the insane temperament, I may in- stance the case of the Alton murderer, who was 174 RESPONSIBILITY IN MENTAL DISEASE. tried, convicted, and executed a few years ago. He was a clerk in a solicitor's office at Alton, Hamp- shire. On a fine afternoon he took a walk outside the town, when he met some children playing by the road-side. One of these, a little girl between eight and nine years of age, he persuaded to go with him into an adjoining hop-garden, and the others he got rid of by giving them a few halfpennies to go home. In a little while he was met walking quietly home ; he washed his hands in the river on his way, and then returned to his work in the office. As the little girl did not return, search was made in the hop-garden, and the dismembered fragments of her body were found scattered about—a foot in one place, a hand in another, and other parts in different places. Suspicion fell directly upon the prisoner, who was immediately arrested. In his desk was found a diary, and in the diary there was this entry recently made:—" Killed a little girl: it was fine and hot." He had killed the child and cut her body to pieces without other motive than the grati- fication of an impulse which suddenly came into his mind. There was no indication of insanity in his conversation or conduct after his arrest, nor was any evidence of strangeness in him immediately before the murder given at the trial. But it came out at the trial, where only the semblance of a defence was made, that a near relative of his father was in confinement suffering from homicidal mania, and that his father had had an attack of acute mania. Moreover, it was proved in evidence by independ- PARTIAL INSANITY. 175 ent witnesses that he himself had been unlike other people, that he had been prone to weep frequently without apparent reason, that he had exhibited sin- gular caprices of conduct, and that it had been necessary at one time to watch him from the fear that he might commit suicide. He was found guilty, condemned to death, and in due course exe- cuted—all the newspapers heartily applauding. Nevertheless the features of the murder in this case were of themselves sufficient to produce a convic- tion in the minds of those who had studied the forms of human degeneracy that there was a strong taint of madness in the murderer—that the disease was at least in the stage of incubation. He was plainly an instinctive criminal, if he were criminal at all: the impulsive character of the crime, the quiet and determined ferocity of it, the savage mu- tilation, his equanimity immediately afterwards, and his complete indifference to his fate—all these indi- cated an insane organization, ill-attempered, a dis- cord in nature, wThich, had it not issued as it did, would, sooner or later, have ended in suicide or in unequivocal insanity. Similar cases have occurred in which women, under the influence of derangement of their special bodily functions, have been seized wdth an impulse, which they have or have not been able to resist, to kill or to set fire to property or to steal. The ques- tion in all such cases obviously is whether the im- pulse was really irresistible or whether it was only unresisted; and this is a question which must be 176 RESPONSIBILITY IN MENTAL DISEASE. answered from a consideration of the facts of the particular case. That the impulse may be irresisti- ble is beyond question. When a woman after her confinement kills her child, whom she loves tender- ly, because she cannot help it, there is no serious disinclination on the part of those who take the legal stand-point to admit that it is not a voluntary act for which she is responsible. The just course would be therefore to abandon a right-and-wrong criterion of responsibility which is contradicted by facts, and from time to time is discredited in prac- tice. That the impulse may be felt and resisted is also a fact which cannot be disputed. It is argued, however, by those who support the legal criterion that if the impulse can be resisted, it makes no dif- ference in the responsibility of the person whether it is owing to disease or not, the object of the law being to make people control their evil impulses, whether sane or insane. Of course it is the duty of every one to control an impulse to homicide, even though it spring from disease, and it may perhaps, without much violence, be assumed that every sane person would be likely to do so, seeing that there cannot be supposed to be any real gratification in doing murder purely for its own sake and in being hanged for it; but to conclude in a particular case that an impulse springing from disease might have been resisted and was not, and thereupon to hang the person, is to assume an insight which no mortal has or can pretend to have, and to do, under the sacred name of justice, a deed which may unques- PARTIAL INSANITY. 177 tionably be a fearful injustice. The punishment will appear the more iniquitous when we further- more reflect that the conclusion is based upon a metaphysical test of responsibility which is proved by medical observation to be false in its application to the unsound mind. Thus much with regard to the insane neurosis in its relations to impulsive homicidal insanity. The second important condition which it is necessary to consider in relation to this form of mental derange- ment is the epileptic neurosis. It is a remarkable and instructive fact that the convulsive energy of the homicidal impulse is sometimes preceded by a strange morbid sensation, beginning in some part of the body and mounting to the brain, very like that which, when preceding an attack of epilepsy, is known in medicine as the aura epileptica. Accord- ingly the sufferer may give a hurried notice of the impending attack, and warn his possible victim to get out of the way. In one of the Annual Reports of the Morningside Asylum, Dr. Skae recorded a striking case, in which the sensation began at the toes, rose gradually to the chest, producing a sense of faintness and constriction, and then to the head, causing a momentary loss of consciousness. It was accompanied by an involuntary jerking, first of the legs and then of the arms, and it was when it oc- curred that the patient felt impelled to commit some act of violence against others or against himself. On one occasion he attempted to commit suicide; more often the impulse was to attack others. He 178 RESPONSIBILITY IN MENTAL DISEASE. deplored his condition, of which he spoke with great intelligence, giving all the details of his past history and feelings.* In other cases a feeling of vertigo, a trembling, and a vague dread of something fearful being about to happen, resembling the vertigo and momentary vague fear of one variety of the epileptic aura, precede the attack. Indeed, medical experi- ence teaches that whenever a murder has been com- mitted suddenly, without premeditation, malice, or motive, openly and in a way quite different from the way in which murders are commonly done, we ought to search carefully for evidence of previous epilepsy, or, should there be no history of epileptic fits, for evidence of an aura epileptica and other symptoms allied to epilepsy. Certainly the most desperate instances of homi- cidal impulse are met with in connection with epi- lepsy. The attack of homicidal mania may take the place of the ordinary epileptic convulsions, being truly a masked epilepsy. The diseased action has been transferred from one nervous centre to another, and instead of a convulsion of muscles the * In a subsequent Report, for 1868, Dr. Skae said of this case : " A case of insanity with a strong homicidal impulse, upon which I commented in my Report for 1866, as being strongly allied to epilepsy, although epileptic fits have never as yet been manifested, has undergone an interesting physiological develop- ment in the same direction, the patient now having almost daily a vivid spectral hallucination in the form of a newspaper. He can see it for a short time so distinctly as to be able to read a long paragraph from it. He continues to suffer from the aura epileptica, and other symptoms allied to epilepsy." PARTIAL INSANITY. 179 patient is seized with a convulsion of ideas. Marc relates the case of a peasant, aged twenty-seven years, who had suffered from epilepsy since he was eight years old; but when he was twenty-five years old the character of his disease changed, and instead of epileptic attacks he was seized with an irresistible impulse to commit murder. He felt the approach of his outbreaks for days beforehand sometimes, and then begged to be restrained in order to prevent a crime. " When it seizes me," he exclaimed, " I must kill some one, were it only a child." Before the attacks he felt great weariness, could not sleep, was much depressed, and had slight convulsive movements of his limbs. Ludwig Meyer relates the case of a boy, aged thirteen years, who was subject to periodical attacks of fury, followed by epileptic convulsions, and who often had the furious maniacal excitement without the convulsions.* Other cases of a like nature might be quoted from works on insanity, but I shall content myself here with mentioning a case, well deserving to be had in remembrance, which occurred not many years ago in England. The man's name was Bisgrove, and he was sentenced to death, together with a man named Sweet, for murder, the judge being perfectly satis- fied with the verdict of the jury. However, after his condemnation, Bisgrove made a confession of the crime, entirely exculpating Sweet from any *Uber Mania Transitoria, von Dr. L. Meyer. Virchow's Archiv, vol. viii., art. ix. 180 RESPONSIBILITY IN MENTAL DISEASE. knowledge of or part in it. The latter accordingly received a free pardon for a crime which he had not committed, and Bisgrove was left for execution. Before this took place a benevolent clergyman, struck with the motiveless and extraordinary character of the murder, made inquiries into his history, the re- sults of which he communicated to the Home Secre- tary. An illegitimate child, and badly cared for, he had been of weak health and intellect from his youth upwards. For several years he had suffered from frequent epileptic fits, in consequence of which he had been discharged from the colliery at which he worked. In the intervals between the fits, he was good natured and gentle, and was liked by his companions; but immediately after the fits he was dangerous, being prone to seize upon anything which might be at hand, and to attack blindly those who were near him. In the hope that a sea voyage might do him good, he went to sea, but returned after some months unimproved; he had lost the bright look of intelligence, and had the heavy, lost look so often seen in confirmed epilepsy. Such was his condition when, one evening, after drinking a little, he wandered out of the town, and saw a man lying asleep in a field. An impulse to kill the man seized upon him, so he took up a big stone which was lying near and dashed out the sleeper's brains. Having done this, he lay down by the side of his victim, and went to sleep. He was taken into cus- tody next day, and in due course was put on his trial for murder, together with the innocent man Sweet, PARTIAL INSANITY. 181 in whose company he had been. At the trial, where, like other poor men who have not means to pay the heavy price which justice costs, he was practically undefended, not a word was said of his epilepsy, nor of his weak intellect, nor of his history up to the events of the night of the murder; he was con- demned, and with him was condemned the innocent man who had given an exact and true account of his actions, but had not been believed. On the earnest representation of the clergyman, who had elicited the facts of Bisgrove's history, he was re- prieved, and, after an examination of the state of his mind had been made, was removed to the Broad- moor Criminal Lunatic Asylum. Had it not been for the happy accident of the confession, the inno- cent man would have been hanged. Had it not been for the energetic interposition of the clergy- man, there can be no doubt that Bisgrove would have been hanged, as other insane persons have been, although the crime itself presented all the most characteristic features of epileptic insanity.* The most dangerous cases with which those who take care of insane persons have to do are those of persons suffering from epileptic mania. Sometimes * Bisgrove has recently made his escape from the asylum, and is still at large, unless, as the authorities of the asylum be- lieve, he has committed suicide. The manner of his escape was significant. He was walking with an attendant, behind whom he got, and whom he knocked down by striking him violently on the head with a brick or stone. He then beat him on the head with the stone, leaving him insensible and apparently dead, and made his escape. 13 182 RESPONSIBILITY IN MENTAL DISEASE. after one fit, more often after a succession of fits, an attack of furious and destructive mania supervenes, marked by blind and reckless violence. This is not a simple impulsive homicidal insanity, the whole mind being in a state of furious derangement, but it is of interest in relation to impulsive insanity—first, because of the blind, destructive impulses by which it is characterised, and secondly, because of the un- doubted occurrence of impulsive homicidal insanity as a masked epilepsy. These are facts of medical observation—first, that an outbreak of irresistible homicidal impulse may occur in a person who has the epileptic neurosis, without there ever having been an attack of actual epilepsy, either in the form of epileptic vertigo or epileptic convulsions; sec- ondly, that it may immediately precede or really take the place of an attack of epilepsy in either of its forms; and, thirdly, that it may follow an attack of epilepsy in either of its forms, " sudden and irre- sistible impulses being," as Trousseau remarks, " of usual occurrence after an attack of petit mal, and pretty frequent after a regular convulsive fit." * * It will help us to realize how near the condition of nerve- element, which we denote by the terms insane neurosis and epi- leptic neurosis, though not itself disease, lies to actual disease into which it may easily and quickly pass, if we pay regard to those cases in which exactly similar mental symptoms follow unquestionable disease. Morel (Traite des Mal. Ment. p. 138) relates the following case: " A man, at 55, sober and industri- ous, had suffered from an attack of cerebral haemorrhage a year ago, and remained hemiplegia His intelligence was sound; and he followed his usual occupation. But his character was PARTIAL INSANITY. 183 Thus much then concerning one variety of affec- tive insanity—Impulsive Insanity, which, beginning with insane idea manifests itself in insane and re- sisted or irresistible impulses to some destructive act of violence. I will now go on to discuss the second variety of affective Insanity—Moral Insanity proper, monomanie raisonnante of Esquirol. 2. Moral Insanity. This is a form of mental alienation which has so much the look of vice or crime that many persons regard it as an unfounded medical invention. Much indignation therefore has been stirred up when it has been pleaded to shelter a supposed criminal from the penal consequences of his offences ; and judges have repeatedly denounced it from the bench as a "a most dangerous medical doctrine," "a dan- gerous innovation," which in the interests of society should be reprobated. The doctrine has no doubt changed: he felt weary of life; he had became morose and irritable ; and he complained that at times the blood rose to his head, when vertigo, noises in the ears, and flashes before the eyes occurred. These attacks became periodic. During them his heart beat violently, his eyes were injected, the face flushed, the fingers of paralysed side contracted, the arteries of neck throbbed; he was unspeakably dejected, wept, said he was lost, and became furious, throwing himself upon his wife and chil- dren, and during the very transitory delirium, instantaneous as it were, had several times attempted suicide. To have controlled the impulse in this case would have been to have controlled the movements of the heart and of the arteries. And what effort of will could have done that 1 184 RESPONSIBILITY IN MENTAL DISEASE. been sometimes used improperly to shelter an atro- cious criminal, but of the actual existence of such a form of disease no one who has made a practical study of insanity entertains a doubt. To the angry declamation of the vexed judge, the sufferer from it might fairly answer in the words of Imogen :— " I beseech you, sir, Harm not yourself with your vexation. I'm senseless of your wrath. A touch more rare Subdues all griefs, all fears." Notwithstanding prejudices to the contrary, there is a disorder of mind in which, without illu- sion, delusion, or hallucination, the symptoms are mainly exhibited in a perversion of those mental faculties which are usually called the active and moral powers—the feelings, affections, propensities, temper, habits, and conduct. The affective life of the individual is profoundly deranged, and his de- rangement shows itself in what he feels, desires, and does. He has no capacity of true moral feel- ing ; all his impulses and desires, to which he yields without check, are egoistic; his conduct appears to be governed by immoral motives, which are cher- ished and obeyed without any evident desire to re- sist them. There is an amazing moral insensibility. The intelligence is often acute enough, being not affected otherwise than in being tainted by the mor- bid feelings under the influence of which the per- sons think and act; indeed they often display an extraordinary ingenuity in explaining, excusing, or PARTIAL INSANITY. 185 justifying their behaviour, exaggerating this, ignor- ing that, and so colouring the whole as to make themselves appear the victims of misrepresentation and persecution. Their mental resources seem to be greater sometimes than when they were well, and they reason most acutely, apparently because all their intellectual faculties are applied to the jus- tification and gratification of their selfish desires. One cannot truly say, however, that the intellect is quite clear and sound in any of these cases, while in some it is manifestly weak. A sane person who is under the influence of excited feelings is notably liable to error of judgment and conduct; and in like manner the judgment and conduct of an insane person who is under the dominion of morbid feel- ings are infected. Moreover, the reason has lost control over the passions and actions, so that the person can neither subdue the former nor abstain from the latter, however inconsistent they may be with the duties and obligations of his relations in life, however disastrous to himself, and however much wrong they may inflict upon those who are the nearest and should be the dearest to him. He is incapable of following a regular pursuit in life, of recognising the ordinary rules of prudence and self- interest, of appreciating the injury to himself which his conduct is. He is as distrustful of others as he is untrustworthy himself. He cannot be brought to see the culpability of his conduct, which he persist- ently denies, excuses, or justifies; has no sincere wish to do better; his affective nature is profoundly 186 RESPONSIBILITY IN MENTAL DISEASE. deranged, and its affinities are for such evil gratifi- cations as must lead to further degeneration, and finally render him a diseased element which must either be got rid of out of the social organization, or be sequestrated and made harmless in it. He has lost the deepest instinct of organic nature, that by which an organism assimilates that which is suited to promote its growth and well-being, and he dis- plays in lieu thereof perverted desires, the ways of which are ways of destruction. His alienated de- sires betoken a real alienation of nature. It may be said that this description is simply the description of a very wicked person, and that to accept it as a description of insanity would be to confound all distinction between vice or crime and madness. No doubt, so far as symptoms only are concerned, they are much the same whether they are the result of vice or of disease ; but there is con- siderable difference when we go on to inquire into the person's previous history—when we pass from psychological to medical observation. The vicious act or crime is not itself proof of insanity; it must, in order to establish moral insanity, be traced from disease through a proper train of symptoms, just as the acts of a sane man are deduced from his mo- tives ; and the evidence of disease will be found in the entire history of the case. What we shall often observe is this—that after some great moral shock, or some severe physical disturbance, in a person who has a distinct hereditary predisposition to insanity, there has been a marked change of character; he PARTIAL INSANITY. 187 becomes " much different from the man he was " in feelings, temper, habits, and conduct. We observe, in fact, that after a sufficient and well-recognised cause of mental derangement—a combination of predisposing and exciting causes which are daily producing it—a person exhibits symptoms which are strangely inconsistent with his previous character, but which are consistent with moral insanity. Or it may appear that there has been an attack of paraly- sis or epilepsy, or a severe fever, and that the change of character and the symptoms of moral alienation have followed one of these physical causes. In all cases, as Dr. Prichard, who was the first to describe the disease, has remarked, there has been an altera- tion in the temper and habits in consequence of dis- ease or of a sufficient cause of disease. Perhaps the strongest evidence of the nature of moral insanity as a disease of brain is furnished by the fact that its symptoms sometimes precede for a time the symptoms of intellectual derangement in a severe case of undoubted insanity, as, for example, a case of acute mania, or of general paralysis, or of senile dementia. It is interesting, indeed, to notice that at least one of Dr. Prichard's cases, on which he founded his description of the disease, was really a case of general paralysis—a disease not specially recognized in his day, but the best known now of all the forms of mental derangement. Surely, then, when a person is subject to a sufficient cause of in- sanity, exhibits thereupon a great change of charac- ter, and finally passes into acute mania or general 188 RESPONSIBILITY IN MENTAL DISEASE. paralysis, we cannot fairly be asked to recognize the adequate cause of the disease and the intellectual disorder as disease, and at the same time to deny the character of disease to the intermediate symptoms. Not only may moral derangement thus go be- fore intellectual derangement for some time and itself constitute the disease, but it constantly ac- companies the latter; so much so that Esquirol declared " moral alienation," not delusion, " to be the proper characteristic of mental derangement." " There are," he says, " madmen in whom it is dif- ficult to find any trace of hallucination, but there are none in whom the passions and moral affections are not disordered, perverted, or destroyed. I have in this particular met with no exceptions." So true is this that disappearance of hallucination or delu- sion only becomes a trustworthy sign of convales- cence after an attack of mental derangement when the person begins to return at the same time to his natural way of feeling. It is hardly to be expected that medical science will, in order not to vex the souls of judges, dissociate the moral from the intel- lectual phenomena in a downright case of madness, and regard the former, because they look like vice, as vice, the latter only as disease, or deem it right to excuse the man for his insane thinking but to punish him for his insane feeling and acts, so far at any rate as these acts are not the direct unqualified offspring of his insane thought. Again, moral insanity may occur in a person who has at one time laboured under another form PARTIAL INSANITY. 189 of madness, being, as it were, a recurrent attack under a different guise: an attack of mania or melancholia comes on and in due time passes off favourably, but on some subsequent occasion he has a genuine moral insanity, which may terminate again in mania or melancholia. There are intervals of what looks for all the world like badness, alter- nating with attacks of what all the world sees to be madness. In the most typical case of moral insanity which has come under my observation there had been previous attacks of melancholia, and it was upon one of these that the moral derangement directly followed. Such cases commonly end in dementia, the disease of mind passing into destruc- tion thereof. French writers have given the names of Folic a double forme and Folie circulaire to a well-marked form of insanity, the characteristic feature of which is excitement alternating with depression. The symptoms are chiefly those of disorder of the moral sentiments, and the two conditions of excitement and depression vary in degree and intensity in dif- ferent cases. In the state of excitement the sufferer is very much like a person who is half intoxicated— loquacious, boastful, aggressive, never weary of talk- ing of himself and of the wonderful things which he can do. And he does things which he would never have dreamed of doing in his sober senses—engages in projects of social or political reform, or launches into commercial speculations, quite foreign to his natural character and habits. His morals undergo 190 RESPONSIBILITY IN MENTAL DISEASE. a sad degeneration : heretofore modest, truthful, and chaste, he is now full of self-glorification, disregard- ful of truth, and given to excesses; he displays a complete indifference to the feelings of those who are related to him, frequents low company, tramples upon social and domestic proprieties, and is angrily impatient of the slightest remonstrance or interfer- ence. Nevertheless he has neither delusion nor ac- tual incoherence of thought, and is capable of giving the most plausible reasons to justify his conduct; his ingenuity in making a good tale for himself by exaggerating, denying, and perverting facts is in- deed most remarkable. He exhibits as great a trans- formation of character as it is possible to imagine. In this condition of exaltation he may remain for months, when, either directly or after a varying in- terval of a return to right reason, he passes into an opposite condition of melancholic depression. How changed now from what he was! Silent and de- pressed, bitterly ashamed of what he has done when he was in his exalted state, profoundly self-distrust- ful, he is unwilling to exert himself, and feels in- capable of discharging the most simple duties. He is overwhelmed with a vague gloom, cannot face the world, perhaps takes to his bed, and may have sui- cidal feelings or even make suicidal attempts. Be- tween the state of excitement and that of depression there may be no lucid break, the one passing directly into the other, or there may be an interval of sanity, of varying duration. This interval generally comes after the excitement and before the depression, but PARTIAL INSANITY. 191 in some cases it is after the depression. The peri- odical recurrence of the opposite states marks a very unfavourable form of mental disease; after it has gone on for a time the interval of lucidity becomes less marked or disappears, the regular alternating character of the phenomena is lost, and there is a steady decline of mental power. There is yet another class of cases of moral in- sanity which ought to receive attention—namely, those that occur in connection with epilepsy. Nothing can be more striking than the abrupt and extreme change in moral character which is wit- nessed sometimes in asylum epileptics before or after an outbreak of epilepsy. Hitherto indus- trious, attentive, and docile, the disposition and conduct undergo a sudden change. They become negligent, lazy, indolent, forget very simple things, will not do their work, but pass their time in in- action or wander about aimlessly ; their disposition too becomes evil—they are for the time liars, thieves, suspicious, discontented and irritable, and on the slightest pretexts, or without actual provocation, yield to sudden outbreaks of violence. The moral perversion is in such case so closely connected with the fits that no one can mistake its nature ; but when an attack of moral insanity occurs, as it may do, instead of the usual epileptic fits—as a masked epilepsy—when such attacks recur periodically for months perhaps before the disease takes its usual convulsive form, then its nature is apt to be mis- taken, and it might go hard with a person who 192 RESPONSIBILITY IN MENTAL DISEASE. committed an offence against law under its in- fluence. Lastly, it should be remembered that the epileptic convulsions may cease to occur in one who has been subject to them, and that in their place attacks of moral derangement with more or less maniacal excitement may appear. Those who suf- fer in this Way commonly find their way into prison sooner or later, and so constitute a part of the crim- inal population of the country. Many cases of moral insanity will be found to be connected with more or less congenital moral defect or imbecility. In a former chapter I have pointed out that one result of descent from insane or epileptic parents is a congenital deficiency or absence of moral sense, with or without a corre- sponding intellectual deficiency. No one would be found nowadays to deny the existence of a congenital deficiency or absence of intellect, or to maintain that all persons, not imbecile or idiotic, have naturally equal intellectual capacities, but there are many persons who still think moral idiocy or imbecility to be a medical crotchet. A deficiency of moral sense, they would say, is a characteristic of the criminal nature, which must be met by a suit- able punishment. But when we find young children, long before they can possibly know what vice or crime means, addicted to extreme vice, or commit- ting great crimes, with an instinctive facility, and as if from an inherent proneness to criminal actions ; when we ascertain that they are the victims of an insane inheritance; and when experience proves PARTIAL INSANITY. 193 that punishment has no reformatory effect upon them—that they cannot reform—it is made evi- dent that moral imbecility is a fact, and that punishment is not the fittest treatment of it. Many remarkable cases of precocious vice and crime in young children have been recorded.* * The following extract from a letter addressed to me gives a sad but faithful account of moral imbecility in a child about whom I was consulted:—" My first experience of Alice was when she was four and a half years old. My feeling about her then was that she was an extremely backward child, but that this might be accounted for by neglectful servants. That I do not now think to have been the case, as she had a good wet- nurse, who remained with her for a long time, and her infancy was tenderly cared for, not only by her father, but also by his mother. I had great difficulty in teaching her to read and count; certain words and numbers she would never under any circumstances repeat. It was at this time that I became im- pressed with the feeling that she was not as other children. Coaxing and punishment were alike unavailing. At five and a half years old she was sent to a good school, where she now is. Her mental progress has surprised me, especially in certain branches of study, but her moral nature remains entirely as be- fore. There seems to be no appreciation of the nature of truth in her, no sorrow for naughtiness, no wish or pleasure to be good, but a great acuteness in slyly persisting in what she has been told not to do. There appear to be times in which she is indelicate in her person, dirty in her habits, nasty with indi- viduals of the opposite sex, and as it were generally inclined to be vicious. She is rarely if ever passionate, but will quietly walk up to a brother or sister and either slap or knock them down without any provocation. In play she will follow the lead of a little brother or sister not half her age, and yet will do dirty and indelicate things with her doll which they would never think of. My aim has been never to leave her alone with the little ones, as I have found, when such has been inadvert- 194 RESPONSIBILITY IN MENTAL DISEASE. Under the influence of the mental revolution which takes place at puberty, moral imbecility is apt to take the more active form of moral insanity, or of actual mania. Cases of this kind obviously bring us very near the class of criminals ; in fact, when a person of the lower orders of society suffers in this way, he generally does something which causes him to be sent to prison, without question asked of the propriety of his fate. If the question be raised whether persons suffer- ing from moral insanity should in every case be ex- empted from all responsibility for what they do wrong, I should shrink from answering it in the affirmative without qualification. They certainly have not the capacity of moral responsibility in its true sense; all the responsibility which they are capable of feeling is that which springs from a fear of punishment. But experience shows that this ap- prehension does influence some of them beneficially, and that the actual infliction of punishment may do them good; that in some few instances at any rate it is the best treatment which can be used. A dis- eased mind, like a diseased heart, may not incapaci- ently done, that she teaches them to do some dirty or disgusting act. I feel that though there is no imbecility or insanity in Alice, she does things which show a distressing want of moral susceptibility. She is now nine and a half years old. I have nothing further to add except that she shows a pleasurable destructiveness both of toys and clothing, and a total want of affection. She can be worked upon only through her conceit or appetite. Her maternal uncle is in an asylum on account of similar deficiencies." PARTIAL INSANITY. 195 tate an individual for all actions, though it may positively incapacitate him for some; as he may do a day's quiet work with disease of the heart, al- though he cannot run a race, so he may be equal to some of the lesser responsibilities of life when he is not quite sane, and not capable of bearing the strain of great obligations. In other instances there can be no question that the persons are not proper ob- jects of punishment in any form; and perhaps in any case the truest justice would be the admission of a modified responsibility, the degree thereof, where it existed, being determined by the particular circumstances of each case. Assuredly moral insanity is disorder of mind produced by disorder of brain. In examining the conditions of its occurrence we have seen how plainly it follows the recognized causes of insanity; how it may precede for a time the outbreaks of various forms of unequivocal general alienation; how it accompanies intellectual insanity in most of its varieties ; how it may follow other forms of gen- eral insanity; how it may precede or follow epilepsy, or occur as a masked epilepsy; how it may super- vene at puberty on congenital moral imbecility; and how it may finally pass into dementia. These are facts of observation. Taking them fairly into consideration, and giving them the weight which they deserve, can we doubt that moral insanity is a form of derangement as genuine as any other form of mental derangement ? If the law cannot adjust the measure of punishment to the actual degree of 196 RESPONSIBILITY IN MENTAL DISEASE. responsibility, and in its regard to the welfare of so- ciety cares not greatly to trouble itself about the individual, that is no reason why we should shut our eyes to facts; it is still our duty to place them on record, in the confident assurance that the time will come when men will be able to deal more wisely with them. Note.—The following extracts from the letters of a young lady who was in a deeply melancholic state furnish a vivid pic- ture of the way in which a suicidal idea may fasten upon the mind, of the mental anguish which it may occasion, and of the strange inconsistency, not uncommon in mental derangement, of a strong inclination to suicide accompanying the belief that death will be immediately followed by the everlasting torments of hell:—" I want you to know how much more the state of my soul has to do with the thought of suicide and with the agony in which I live than you would have any idea of from our short interview of yesterday. 1 left school at eighteen, and I am now thirty-one years of age. I cannot remember ever having the thought of destroying myself or any one else before leaving school, but I do remember now that many years ago I was every now and then distressed with the idea. 1 heard a long while ago that two of my great-uncles had destroyed themselves, and that made me fear that I had inherited insanity. But now with regard to the exercises of my soul. You, I suppose, regard my brain as the cause of all I suffer ; I cannot for one moment be- lieve that. It is something that cannot be reached by any reme- dies, I am sure. Every day and all the day I have before me my past life with all its privileges, mercies and sins—my whole character clearly before me in every point—the maddest re- morse at knowing that up to this moment I have lived without God in the world, although outwardly so exemplary in many respects. I have such thoughts of time and eternity, heaven and hell, the soul and the body, and the relative importance of things material and spiritual as I believe no one has who is not on the verge of eternity. 1 have the inexpressible agony of PARTIAL INSANITY. 197 knowing that my life is over so far as any possibility of salva- tion is concerned. Can you—no, you cannot—picture to your- self the anguish of one who has loving parents, brothers and sisters—all Christians going to heaven, a beautiful home, every- thing external to give nothing but happiness, yet so intensely realizing that there is nothing but Hell before her, that she does not know how to endure existence from day to day. You talk of my case as bad but not hopeless. I know that it is hopeless. I know that the worm that dieth not, that the fire that is not quenched, is raging within me. Burning memories consume me every day, and I ask you what rest there can be for the brain when the soul is in such a hopeless state." In another letter, written about six weeks afterwards in the same strain, she says: —" I cannot and do not believe (Oh ! how I wish I could) that there is now sufficient cause in my body for my anguished state of heart and soul: it seems utterly impossible to me. Then another thing strikes me very forcibly. I was not getting grad- ually more susceptible when I heard of a murder or suicide. I had had no sudden shock; indeed I had felt worse several years before. And yet without the slightest warning the thought came, was intermittent for three or four weeks, and then on my return home in July the thought was completely fastened upon me, so that I could not forget it one minute when awake— wherever I was, or whatever I was doing, positively I could not, although I longed to do so—for I had no desire, no motive, to commit suicide. How could I possibly have ! But very soon I became religiously depressed, and about the middle of August I felt sure that I was lost for ever without the possibility of par- don. . . . Now I want you to see this very plainly that whereas at first I had every minute the thought of suicide without any motive to commit it, now and for a long time past the very hell in which my lost soul lives makes me so desperate that I feel as though 1 could not continue in the body—wo motive at first, though certainty of hell for ever now driving me to it. . . . What life has been, and what it should have been in every respect, I see now with the agony of one who knows that the probation is over, and that there is nothing but death and hell before him. Only with me I have not the privilege of being diseased 14 198 RESPONSIBILITY IN MENTAL DISEASE. in body, and thus stricken to death. I have got to put an end to myself through very agony of heart and soul—an unforgiven, lost soul. Now, can you truly say that weak nerves produce all this? Oh ! it is not so. I am quite sure that I shall never again return to my home and family. Such bliss will never be for me. God will not thus rescue me from the very jaws of hell, for there it is, I assure you, that I am. And one day you and my friends will know that I was a terribly true prophetess." There are indications of mental improvement in some of the expressions in that letter, which were confirmed by the next, re- ceived a fortnight afterwards:—'■ I wished to be the first to have the pleasure of telling you of my decided improvement, but Mrs.----has forestalled me. I was afraid of acknowledging it at first, lest the fancied change should prove a delusion. Mer- cifully it was not so. Oh ! how different I am from what I was even a week ago. . . . Still my thoughts run so much in one groove. The idea of suicide constantly there, without however the wish to commit it. Do you think the time will ever come when for a whole day I shall never even think of it ? I cannot yet imagine such freedom. I feel like one turned back from the brink of the grave to life and home and friends-again— verily, I have been in a chamber of horrors! How glad I shall be to think less of myself !" After a little time more, she re- covered entirely. CHAPTER VI. PARTIAL INSANITY. II.—Partial Intellectual {or Ideational) Insanity. Simple melancholic depression preceding intellectual derange- ment: 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 pre- ceding an outbreak of homicidal mania : the characters of the attack—Dangerous character of the insanity that is ac- companied by delusions of persecution—An insane person does murder out of revenge: is he a responsible agent ?— Futility of argument against a delusion: a limited delusion indicates deeper mental derangement: examples—Premedi- tation in planning and ingenuity in perpetrating homicide entirely consistent with insanity: example—Danger of re- currence 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 cannot 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 delu- sion: 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 impos- sibility of tracing its workings—Pathological meaning of the existence of an insane delusion, however limited—The 109 200 RESPONSIBILITY IN MENTAL DISEASE. right problem in homicidal insanity is to trace a connec- tion, not between the delusion and the act, but between the disease and the act. While admitting the existence of simple impul- sive insanity, it must be acknowledged that most often symptoms of derangement in addition to the morbid impulse, either antecedent to or concomitant with it, will be discovered, if a careful enough ex- amination be made—such symptoms as previous marked melancholic depression, morbid suspicion, or actual delusions. It will be found that many of the suicides and homicides done by insane persons are done by persons labouring under commencing melancholia, before the disease has developed into the stage of intellectual derangement; though over- whelmed with a vague fear or distress, dejected, sleepless, and feeling themselves overladen with the heavy burden of their miserable lives, they manifest no actual delusion, and are not thought by their friends or medical attendants ill enough to be placed under control. Of this kind apparently was the homicidal in- sanity of Charles Lamb's sister, Mary Lamb. Worn down to a state of great nervous depression by at- tention to needlework during the day and to her mother by night, she " had been moody and ill for a few days previously," says her brother's biographer, and the illness came to a crisis on the 23rd Septem- ber. On that day, just before dinner, she seized a caseknife which was lying on the table, pursued a little girl (her apprentice) round the room, hurled PARTIAL INSANITY. 201 about the dinner forks, and finally, in a fit of uncon- trollable frenzy, stabbed her mother to the heart. Her brother was at hand only in time to snatch the knife from her before further hurt could be done. He found his mother dead, and his father, who was in his dotage, bleeding from a wound on the fore- head which he had received from one of the forks. She was sent to an asylum, where she recovered her reason in a short time, returning thence to live with her brother. Recurrent attacks of insanity afflicted her for the rest of her life, but when the indications of an attack presented themselves, she placed herself or was placed under care in an asylum. Homicidal or suicidal insanity supervening on melancholic depression, with or without delusion, may be accepted as the usual order of its occurrence. A mother, worn down by anxiety and ill-health, be- comes very low-spirited and desponding, imagines perhaps that her soul is lost, or that her family are coming to poverty, and one day, in a paroxysm of despair, kills her children in order to save them from misery on earth, or because she is so miserable that she knows not what she does. Under the in- fluence of a like depression and like delusions a hus- band kills his wife. The symptoms exhibited by him before the act may be limited to great mental dejection of a hypochondriacal character, moodiness and loss of interest in all things, and perhaps a morbid feeling of despair concerning the state of his health or the state of his affairs; his friends ob- serve nothing more in him than that he is " very 202 RESPONSIBILITY IN MENTAL DISEASE. low," and, if they belong to the lower class, will probably describe him as " studying too much," by which they mean brooding too much. Suddenly on some occasion his mental suffering rises to such a pitch of anguish or agony that he falls into a parox- ysm of frenzy, during which he loses all self-control, and does violence to himself or some one else, not knowing at the time what he is doing, and being horror-stricken afterwards when he realizes what he has done. By the homicidal deed, which has been truly described as a raptus melancholicus, he is freed from his terrible and overwhelming emotion, returns perhaps to himself, and may display no present symptom of insanity. In such a case the delusion has no evident bearing upon the act, although both delusion and act are the manifest offspring of the insanity; the passing frenzy is a pure convulsion of mind springing from that diseased state of the nerve- centres of mind, of which the depression and delu- sion are also expressions. In other cases, however, it will be found, on inquiry, that there has been a suddenly arising hallucination or delusion which has accompanied the act; a loud roaring sound in the ears, or a redness as of fire or of blood before the eyes, or a sulphurous smell in the nostrils, testifying to the disorder which has seized upon the sensory nerve-centres. One example will serve as an illustration of a class of cases. At the Derby Assizes, on December 16th, 1871, Samuel Wallis, a shoemaker, was in- dicted for the wilful murder of his wife, with whom PARTIAL INSANITY. 203 he had always lived on the most affectionate terms. He had stabbed her in the neck in the night with a shoemaker's knife which he kept in the room for the purposes of his work, and had then walked away. When apprehended, he was excited and said—" I was up in the fields, and then I went down into the colliery. I came out again about dark. There was such a fearful thundering noise in the pit, I was so glad to get out. Brampton looked so black and dark, and trains were running up and down as fast as they could." The pit had not been worked for a long time, so that there could have been no noise, nor were there any trains run- ning at Brampton. At the trial, a surgeon, who had attended the prisoner for some time, gave evi- dence that he had suffered from derangement of the stomach and liver and dejection of spirits, and that he was under the delusion that he would never re- cover. He had been sent away for change of air, but had only stayed one day, and he was to have gone away again on the very day of the murder. The witness gave it as his opinion that it was a case of homicidal mania, basing this opinion on the com- plete absence of motive, the nature of the act, the previous symptoms of mental disorder, and the sub- sequent conduct. The surgeon of the gaol gave a similar opinion, and said that the prisoner had stated to him that the act was so impulsive he did not know what he was doing, and was horror-stricken when he discovered what he had done. The judge, in summing up, pointed out that there was no evi- 204: RESPONSIBILITY IN MENTAL DISEASE. dence of insanity at any other time, that he had no delusions, nor had his conduct been eccentric. Still there was a complete absence of motive for the crime, and if they felt satisfied that he was in a state of frenzy at the time, and unconscious of the nature of the act he was doing, they must find him " Eot guilty." "It might become a dangerous thing to permit this kind of defence to prevail; nevertheless, if they were perfectly satisfied it was so, they must say so." The jury found him guilty, but recom- mended him to mercy on account of previous weak- ness of mind! He was sentenced to death, but the sentence was not carried into effect. Had he been tried by some judges, it is certain that he would have been executed, as other similarly insane per- sons guilty of homicide have from time to time been. Had there been any ground for alleging ill- feeling against his wife, it is almost certain that, notwithstanding the testimony as to his insanity, he would have been executed. Had judge and jury really known anything of the nature of insanity, he certainly would not have been found guilty, but would have been acquitted at the trial on the ground of insanity. On examination of the recorded instances of homicidal insanity, it will be found that many of them have been delusions of suspicion or persecu- tion accompanying the melancholic depression. The individual has believed himself to be continu- ally insulted, reviled, followed, robbed, poisoned, or ruined in health and property, and has done homi- PARTIAL INSANITY. 205 cide under the influence of such insane delusion. The following case is an instructive example :—Dr. Pownall, a medical practitioner, was admitted into the private asylum of JSTorthwoods, under the care of Dr. Davey, on April 2nd, 1859. He was de- scribed in the medical certificates, which were dated on the same day, as " having made a murderous at- tack on his mother-in-law, wdiom he usually re- spected and loved ; " " for the last three months he had become an altered man," had been "low and desponding," and " he had made an attempt to de- stroy himself." This was the third attack of aliena- tion, the first having occurred when he wras twenty- two years of age, the second after an interval of fourteen years, and the third after another interval of four years and a half. Between the attacks he had conducted successfully a large medical practice, and had been so much respected by his fellow- townsmen as to have been chosen mayor of the town. He was described as being naturally an amiable and estimable man, but when insane, as violent and dangerous to himself and others. The first indications of mental derangement were a mis- trust of his nearest relatives and a suspicion of de- sign on their part against his interests; these symp- toms being followed, after a time, by delusions that poison was mixed with his food and that he was otherwise injured, and by suicidal and homicidal violence. During his second attack of derange- ment, in 1854, he had shot a gentleman with whom he was out shooting; and although the coroner's 206 RESPONSIBILITY IN MENTAL DISEASE. inquest resulted in a verdict that the fatal injury was accidental, there were some who thought differ- ently. On his arrival at Northwoods, Dr. Davey, who had an interview with him, found him a little agi- tated, but nothing more. He conversed in a calm and gentlemanly manner, and as the conversation was continued, wept and expressed the deepest sor- row for his violence to his mother-in-law; when asked to give up anything about him with which he might injure himself or others, he at once gave Dr. Davey two penknives. Thenceforward his behav- iour and conversation were quiet and rational; he joined Dr. Davey's family and children in their walks, and rode out with him and his son. He re- mained in the asylum for four months, and during the whole of that time betrayed no symptoms of mental disease, so that he was considered to be quite well, and was discharged as recovered on the 10th August. Regard being had to his antecedents, however, he was sent to the house of a medical man and was accompanied by an attendant. Twenty days after leaving Northwoods, on the 30th August, he killed a female servant by cutting her throat with a razor, having shown no indication of insanity up to within a few hours of the act. Acquitted at his trial on the ground of insanity, he was sent to Bethlehem Hospital as a criminal lunatic, where he was under the care of the late Dr. Hood, who, speaking of his case after an observation of several months, said that " from that time up to the pres- PARTIAL INSANITY. 207 ent, although he had watched him with no ordinary care, he did not know that he could attach any par- ticular symptom of insanity to him," and that " sup- posing he was a private patient in my asylum, and the Commissioners of Lunacy asked me why I de- tained him, I do not know that I could give any definite reason for it." By the unhappy event in this case it was ren- dered plain that Dr. Pownall belonged to one of two classes of patients : either he was subject to periodical attacks of recurrent mania, or, as is more probable, he was able successfully to conceal his de- lusions when he had a strong motive to do so, and was living under conditions favourable to the main- tenance of tranquillity of mind. Whichever be the true explanation, one thing is certain—that a man may present all the appearances of sanity, so as, if insane, to deceive the most skilled observers, unto the time of a fatal outbreak of homicidal mania. Of the fact that insane persons are capable of con- cealing for a long time in a complete manner their delusions of suspicion and persecution, there can be no doubt; and this successful concealment of them, where they are known to exist, renders it not im- probable that they have been present, undetected, in some cases of what has been supposed to be im- pulsive homicidal insanity. But if a person may thus skilfully simulate sanity, when he feels it to be his interest to do so, it might naturally be argued that he exhibits sufficient clearness of consciousness and sufficient strength of will to make him justly 208 RESPONSIBILITY IN MENTAL DISEASE. responsible for an act which he knows to be a crime, and which he proves by his conduct he is not with- out will to resist. Granting that Dr. Pownall acted, as no doubt he did, under a delusion that the servant whom he killed had injured him in some way, and that the murder was the effect of the de- lusion, it might still be contended that he was re- sponsible for what he did ; for supposing the imag- ined injury to have been real—supposing, in fact, his belief not to have been a delusion, a man so sane in other regards must have known that to take her life was a crime punishable by death. Know- ing this, had he the power to resist the impulse to kill her ? This was really the vital question in the case, as it is in other cases of homicidal insanity. We shall not be in a position to form a right judgment concerning any case of this kind unless we distinctly realize the possibility of an impulse to violence in an unsound mind becoming at times per- fectly uncontrollable. That must be admitted as a general proposition, the question whether the im- pulse was uncontrollable in a given case being de- termined in accordance with the particular facts. There are sometimes striking coincidences between the exacerbations of the mania and disturbances of the bodily health. Before an outbreak of homici- dal impulse it may be found that there has been a change in the patient's symptoms, physical and men- tal ; his tongue is white, he is feverish, feels faint and ill, loses his spirits, is suspicious, anxious, and disquieted; these are symptoms which in 6uch a case PARTIAL INSANITY. 209 are sometimes forerunners of the attack. When this breaks out, the mind is overwhelmed with such a vast and painful emotion, such an unspeakable feeling of anxiety and distress, that the deed of vio- lence is, as it were, an explosion of it, an uncon- trollable convulsion of energy giving utterance to an indescribable morbid feeling ; knowing not what he is doing, he kills some one, friend or fancied enemy, or perhaps an entire stranger, not really from passion or revenge or enmity of any kind, but as a discharge which he must have of the terrible emotion with which he is possessed. The emotion corresponds in the higher centres of thought with the hallucination in the sensory centres, and the act which discharges it is as involuntary as the cry of agony or the spasmodic muscular tension produced by intense physical pain. Hence there are four things noticeable in homicidal mania : first, the par- oxysmal nature of the actual violence, which takes place only when the emotion becomes unendurable, the idea or impulse, though present, being almost passive in the intervals ; secondly, the mighty relief which the patient feels directly he has done the deed, so that he is delivered from the extraordinary disquietude which he had previously felt and may give a rational account of himself; thirdly, the fre- quency with which the attack is made upon a near relative or upon any one, friend or stranger, who happens to be at hand when the paroxysm occurs; and, fourthly, the indifference which he displays afterwards to the dreadful nature of what he has 210 RESPONSIBILITY IN MENTAL DISEASE. done, which, having been done wdien he was alien- ated from himself, was not more truly his act than convulsion is an act of will. It is hard to dive into the depths of a diseased mind, and quite impossible for a sane mind to realize what passes there, but so far as a description can be given, from a psycho- logical point of view, of the state of mind of the homicidal madman, the records of experience indi- cate that it is what I have endeavoured to picture. Assuredly it is unjust to him to assert that he can always control an act which he knows theoretically to be wrong. The fear of death has no influence whatever to strengthen the power of control during the paroxysm of painful emotion which overwhelms reflection; a greater fear, the fear of hell and all its horrors, is of no avail in a mind deeply imbued with religious feeling to prevent suicide under similar circumstances. The sufferer is the victim of dis- ease and a proper subject for medical treatment, not a criminal and a proper subject for legal pun- ishment. It sometimes happens in the case of a person labouring under delusions of persecution that an act of violence against others, which is attributed per- haps to the excitement of intoxication, is the first circumstance to betray the unsound mental state. The delusion may be concealed for a long time, not- withstanding persistent efforts to elicit it, when he suspects any danger to himself from the avowal of it. One of my patients, who had for some time had delusions that people in the streets, in hotels, PARTIAL INSANITY. 211 and elsewhere were speaking ill of him, accusing him of vices of which he was innocent and other- wise persecuting him, wras sent to an asylum on ac- count of an outbreak of excitement in the middle of the night, during which he smashed the windows of the house and made a savage attack upon his mother. Before this scene he had been extremely cautious about giving utterance to his delusions, but when he found into what trouble they had brought him, it was impossible to elicit an avowal of them. Accordingly, after being some time in the asylum, he was discharged. Two years afterwards he con- sulted me about the persecution and torture to which he believed he was subjected night and day by being played on by electricity and mesmeric tricks, his whole muscular system being kept in a constant succession of jerks thereby; and on that occasion he confessed to me with some glee that he concealed and denied his delusions in the asylum, though he had them all the while, because he found he would not be released by the authorities if he confessed them. In these cases it is often most difficult to advise; for, on the one hand, a person, though labouring under delusions of the kind, may go on for years in the world without compromising himself by any act of violence, wherefore it seems a harsh and unneces- sary measure to place him under restraint; on the other hand, he may break out into dangerous vio- lence at any moment. More or less dangerous therefore at all times, patients of this class are most 212 RESPONSIBILITY IN MENTAL DISEASE. dangerous when the delusions of persecution are accompanied by a hypochondriacal gloom and de- pression, with abnormal sensations in the stomach, liver or other organ, and especially when, as some- times happens, they imagine they hear a singular voice in the chest or stomach ; believing that their bodily sufferings are caused by the persecutions to which they are subjected, or obeying the imaginary voices which they hear, they are apt to revenge themselves on those whom they believe to be the causes of what they undergo. Oftentimes they first appeal in vain to the police or to persons higher in authority, wdiereupon they conclude that these are implicated in the conspiracy against them, or at any rate bribed to do nothing in the matter, and finding that they can nowhere get redress, they are driven to desperation, and fall back upon the inherent and inalienable right of man to protect his life at any cost. Or they do an insane act of violence in order to compel attention to their extraordinary case and to have the opportunity of declaring publicly in a court of justice what they have suffered, when the truth shall be made known and their persecutors confounded. When an insane person kills some one whom he believes to have injured him in health, property, or reputation, and when the act is done therefore out of revenge, what are we to say of his responsibility ? The English law, as we have seen, declares him to be liable to the punishment which would be inflicted if he were not insane; the disease is considered to PARTIAL INSANITY. 213 make no difference in his culpability; the act is deemed to be his act notwithstanding his alienation. Moreover, the popular notion that a really insane person acts without motive, or at any rate not from the same motives which influence a sane person, strengthens the erroneous belief that when he acts out of revenge he is not truly insane or is not acting insanely. But a person does not, when he becomes insane, take leave of his human passions nor cease to be affected by.ordinary motives, and when he acts from one of these motives he does not, by do- ing so, take leave of his insanity ; if he kills some one out of revenge for an imagined injury he is still a madman taking his revenge. Nothing is more certain than that the inmates of lunatic asylums perpetrate violence of all kinds and degrees under the influence of the ordinary bad passions of human nature. The question then is, whether it is just to hold a madman who acts from revenge equally re- sponsible with a sane person who does a similar act in a similar spirit. To answer in the affirmative unhesitatingly seems verily a bold if not a reckless thing when it is remembered that insanity is the effect and evi- dence of loss of power of will produced by disease, and that the final result of its increase is a complete abolition of will. The truth is, that what in the same mind is controllable passion becomes in the insane mind uncontrollable insanity. The madman has an insane delusion that his neighbour is continu- ally persecuting him in some absurdly impossible 15 214 RESPONSIBILITY IN MENTAL DISEASE. way; he knows at the same time that it is against the law of God and man to do murder, and he withstands for a long time the impulse of passion which insti- gates such vengeance; perhaps he denounces his persecutors to the authorities and appeals for re- dress ; but at last, either from further deterioration of health causing a greater activity of the delusion and less power of will, or from the great provoca- tion of the occasion, he is driven to desperation, passion drowns reflection, sweeps away the trifling resistance of an enfeebled will, and hurries him into the deed of angry vengeance. To say of such an one that he has no power of control, or to say of him that he has the same power of control as a sane person, would be equally untrue. To be strictly just, we must admit some measure of re- sponsibility in some cases, though not the full meas- ure of a sane responsibility in any case; at the most, we must admit an insane responsibility, such as is recognized in the management of asylums, where the insane are worked upon by ordinary motives, but are not punished as fully responsible agents when these motives fail to hold them in check and they break out into violence. It is of course impos- sible to measure with anything like exactness the intensity of a morbid impulse and the degree of re- sistance which the will may be capable of opposing to it; some may have yielded to temptation, though convinced that they ought to have resisted it, and are therefore so far culpable ; but the disease with which they are afflicted is already so great a calamity that PARTIAL INSANITY. 215 the infliction of the extreme punishment of death would certainly seem " an inhumanity towards the defects of human nature." No power of will can hold in check the progress of disease, and it is truly a piece of strange irony to exact such a controlling power in a disease the special character of which is to weaken the power of will and to increase the force of passion—to lessen the power of controlling what is more difficult of control. It will be enough to secure the community against the repetition of the offence by enforcing confinement for life. Let it be considered furthermore that an insane person's revenge for a fancied injury is truly a pas- sion which springs from his disease; that it is the direct, and the act which it instigates the indirect, offspring of the delusion; and that what is de- manded of him is that he should control a passion which is generated by morbid beliefs over which he has no control. It is impossible so to divide the personality into two distinct parts, one of which is in subjection to a morbid idea and irresponsible, while the other remains master of itself and respon- sible. The theory of such a division is most extraor- dinary when applied to the will and moral liberty— to that which constitutes in the highest degree the unity of the human personality. Let any one who thinks otherwise converse freely with an insane per- son who has delusions of persecution—that he is watched, insulted in the streets, maliciously pursued and denounced wherever he goes, and who, apart from these delusions, appears to be as rational as 216 RESPONSIBILITY IN MENTAL DISEASE. other men are; let him reason exhaustively with him and try to convince him of the error of his foolish belief; let him demand what evidence he has to warrant it, listen to it seriously, and then demonstrate how inconclusive and inconsistent it is; let him set forth to him how absurd it is to suppose that any person should for no known reason pursue him as he imagines he is pursued, and how little they can have to gain by it; let him point out further that no one else can discover the least evi- dence of what he believes, but that every one else considers it utterly impossible: let him exhaust, as he may in vain, all the resources of argument in his endeavour to shake the delusion ;—he will part from him a wiser and a sadder man in his knowledge of the extent of mental derangement which is betrayed by a limited delusion. Not long ago I tried all this with a most intelli- gent and highly cultivated gentleman who believed that there was a conspiracy against him, and that wherever he went in his travels through all parts of Europe he was followed and watched by the secret agents of his enemies. He acknowledged the justice of my arguments, admitted that all that he had ob- served and misinterpreted in the demeanour of those whom he suspected was consistent with two theories—the theory of their innocence as well as that of their guilt, and confessed that while the former was reasonable and probable, the latter was most unreasonable and in the highest degree im- probable ; owned that he himself felt at times that PARTIAL INSANITY. 217 he must be mad, and should probably consider any one else who believed as he did to be so ;—and, I need hardly say, went his way without bating one jot of confidence in his delusions. Baillarger tells a story which teaches the same lesson in a striking way. When M. Trelat was intrusted provisionally with the management of the Bicetre, he had under his charge a patient who believed that he had solved the problem of perpetual motion. After having in vain employed all the arguments which he could make use of to shake the delusion, the idea occurred to him that perhaps the great authority of Arago would have the most beneficial effect in convincing his patient. Arago, after having received the assur- ance that insanity was not a contagious malady, agreed to combat the delusion. The patient was taken to his study, where A. von Humboldt hap- pened to be. When the poor madman heard from M. Arago the firm and convincing disproof of his error, he was as it were stupefied, shed abundant tears, and deplored the loss of his illusion. The end which they had in view seemed to be attained, but M. Trelat and his patient had hardly gone twenty paces from the house when the latter turned to him and said—" It is all one ; M. Arago deceives him- self ; I am in the right." The delusion of eternal damnation is not uncommon in the melancholic form of insanity, and the friends of an insane per- son labouring under this terrible delusion will some- times vainly try what the authority and arguments of a clergyman will do to dissipate it—in one case of a 218 RESPONSIBILITY IN MENTAL DISEASE. patient under my care a distinguished bishop's aid was invoked in vain—no reasoning will touch its foundations— You may as well Forbid the sea for to obey the moon, As or by oath remove or counsel shake The fabric of his folly. The very fact that an insane delusion does per- sist in the mind is proof enough that the man can- not reason soundly: he will reason insanely, feel insanely, and sooner or later act insanely. Its foun- dations are not laid in reason, but in disease; and it holds its ground in the mind just as a cancer or other morbid growth holds its ground in the body,—by drawing to its own use and converting to its own nature the nutriment which should support healthy activity, and so render its existence impossible. A cancer is physiologically illogical; nevertheless it persists, and finally kills the patient, being patho- logically logical. In like manner an insane delu- sion, though psychologically unaccountable, has its foundation in the inexorable logic of pathology, and persists by perverting to its own use and mainte- nance the reasoning which should render its exist- ence impossible. In the case of the delusion, as in the case of the cancer, we are concerned to observe the pathological phenomena, and to find out their laws ; physiology will not help us much in the one case, nor psychology in the other; our investigations must follow the paths of inductive inquiry. To PARTIAL INSANITY. 219 hold an insane person responsible for what he feels and does in consequence of his insanity, would be no less unjust than to hold him responsible for en- tertaining his delusions, in spite' of the plainest evi- dence to contradict them. Before taking leave of these cases of homicidal insanity in which there have been delusions of sus- picion and persecution, let it be noted that there may sometimes be the clearest evidence of premedi- tation in the plan and of ingenuity in the execution of the deed. It is entirely consistent with insanity that the individual, knowing in the abstract the dif- ference between right and wrong—nay more, know- ing that he is doing wrong in the particular instance —should contrive the means of murder, do it delib- erately, and endeavour to escape the consequences afterwards. This is a statement which is not easy of acceptation by those who, measuring the workings of an unsound by the standard of a sound mind, conclude that he who shows so much reason and self-control in his manner of doing an ill deed, might use that reason and self-control to forbear doing it; nevertheless, it is a generalization from experience, which no one who has a practical knowl- edge of insane persons will contest, and which no one'who has studied scientifically the pathology of mind will find unphilosophical. A striking instance of the cool and daring cunning of insanity, and of the sense of responsibility that may accompany it, is related by the American writers Wharton and Stille—writers who are far from exhibiting an undue 220 RESPONSIBILITY IN MENTAL DISEASE. indulgence in estimating the responsibility of the insane:— " A man named John Billman, who had been sent to the Eastern Penitentiary of Pennsylvania for horse-stealing, murdered his keeper under cir- cumstances of great brutality, and yet with so much ingenuity as to elude suspicions of his intentions and almost conceal his flight. He hung a noose on the outside of the small window which is placed in the door of the cells to enable persons outside to look in; he then induced the keeper, in order to look at something on the floor directly at the foot of his door, to put his head entirely through; the noose was then drawn, and but for an accident the man would have been strangled. Notwithstanding this attempt, the same keeper was inveigled into the cell alone a few days afterwards, on the pretence of Billman being sick, and was there killed by a blow on the head with a piece of washboard. Billman undressed him, changed clothes with him, placed him on the bed in such a position as to induce the general appearance of his being there himself, trav- ersed in his assumed garb the corridor with an un- concerned air, addressed an apparently careless ques- tion to the gate-keeper, and sauntered listlessly down the street on which the gate opened. He wTas, how- ever, soon caught; but his insanity was so indisput- able that the prosecuting authorities, after having instituted a careful and skilful medical examination, became convinced of his irresponsibility, and united upon the trial in asking a verdict of acquittal on the PARTIAL INSANITY. 221 ground of insanity. He was then remanded for confinement under the Pennsylvania practice; and some time afterwards, when in a communicative mood, disclosed the fact of his having several years back murdered his father under circumstances which he detailed with great minuteness and zest. In- quiries were instituted, and it was found that he had told the truth. The father had been found strangled in his bed, the son had been arrested for the crime, but so artfully had he contrived the homicide, that he had been acquitted by means of an alibi got up by means of a rapid ride at midnight and a feigned sleep in a chamber, into which he had clambered by a window. Here was not only a sense of guilt, but a keen appreciation of the consequences of exposure, and an abundance of evidence of long- harboured intention and intelligent design." Another lesson which may be drawn from this case is one which sad experience of homicidal mania has often taught—namely, the exceeding danger of a recurrence of the attack. One can hardly ever say of a person who has once laboured under it that he has recovered entirely, so sudden, unexpected, convulsive may be the outbreak of a paroxysm. Pinel mentions the case of an inmate of the Bicetre, who, sixteen years after he had strangled his chil- dren, assassinated two of his fellow-patients. And Esquirol relates the case of an advocate, of a gloomy and taciturn character, who was placed under his care on account of an attack of insanity in which he had attempted to throw himself out of 222 RESPONSIBILITY IN MENTAL DISEASE. the window. During his illness he accused his wife of infidelity, believed himself damned, made at- tempts at suicide, and for a time refused food from fear of poison in it. After three months he seemed to be convalescent, and was removed by his wife. On their way home, though very affectionate to her and conversing reasonably, he had an angry alterca- tion with a passenger who sat opposite to his wife, and of whom he was jealous. On the day after his arrival home he took by the hair, as if to play with him, a boy of twelve years of age, his wife's brother, led him towards his desk, and then let him go, saying, " It is not worth while." On the third day he went into the cellar, accompanied by his wife, under the pretext of seeing whether all was right there. A few minutes afterwards his sister- in-law, aged twenty years, followed. As no one re- turned, a servant went down to see what was the mat- ter ; she found the two women dead, bathed in blood, while he was crouched in a corner behind some bar- rels, a razor lying some distance from him. He was sent to Charenton. At one time he said that the cellar was lightened in a brilliant manner, and that the two ladies were devils who had come to seize upon him; at another time he declared that he did not know what he was doing. It was very doubtful, however, whether hallucination had any- thing to do with the murder, for he had evidently thought of killing the boy two days before, and he must have taken the razor into the cellar with a homicidal design. After being some time in the PARTIAL INSANITY. 223 asylum he seemed to have recovered, although he showed a remarkable insensibility to the remem- brance of what he had done. He wrote numerous letters to the authorities, declaring that he had been mad, that he was cured, and that he ought to be put in charge of his property and children. After hav- ing made these demands for several years, he was examined by Marc, who could not discover any in- tellectual disorder :—" I remained," he said, " at least an hour and a half alone with him, and during the long conversation which we had together, I was not able to detect the slightest trace of mental dis- order ; but I was struck with his indifference when I spoke with him of the double homicide which he had committed." Notwithstanding that Marc de- clared that it would be imprudent to grant him his liberty, his importunities ultimately obtained it. He established himself with a woman in Paris, where he opened an office. Two years after his discharge, and ten years after the invasion of his disease, he was seized with a new attack of fury, and but for the vigorous resistance of the woman with whom he lived, he would have thrown her out of the window. He was sent to an asylum, wdiere he died after some days of fearful delirium, in which he wished to kill himself and every one else. There is nothing uniform, immediately after- wards, in the conduct of patients of this class who have done or attempted to do homicide. In some the memory is obscure and confused, they scarcely understand what has happened, and they make no 224: RESPONSIBILITY IN MENTAL DISEASE. attempt to escape ; others realize vividly what they have done as soon as the overwhelming emotion has been discharged in the act, and, obeying the reviv- ing instinct of self-preservation, do at first attempt to escape, though they probably surrender them- selves to justice in a little while. Some manifest a complete moral insensibility, seem perfectly indiffer- ent to what they have done, and utterly unable to realize its criminal nature; while others, when they come to themselves after the deed, display the keen- est anguish and remorse. Attempts at suicide both before and after the homicide are not at all un- common. I proceed now to consider another class of cases of homicidal insanity—those in which there is a definite delusion in the mind, and the crime is the direct or indirect result of the delusion. When a father believes that he has received a command from Heaven to slay his son, and obeys it, there can be no manner of doubt of his insanity, and no one would impute the deed to him as a crime: it was the direct unqualified offspring of the delusion. Even lawyers admit readily that this kind of in- sanity excludes all responsibility for actions which can be shown to be in close relation to the particu- lar delusion under which the so-called monomaniac labours ; the vital question for them being how far the delusion has affected the mind of the agent at the time. No human punishment, it is supposed, would restrain him from doing what, though legally criminal, he believes it right to do; his knowledge PARTIAL INSANITY. 225 of right and wrong in this regard is destroyed by disease. But if the delusion cannot be shown to have influenced the act—if a man has the maddest delusion which madness can imagine, and does a murder which cannot be traced to its influence— then it is declared that he ought not to be absolved from culpability; that he ought justly to be held responsible in all other instances. Hoffbauer pro- posed that, in order to answer the question of re- sponsibility in regard to the acts of insane persons, " the dominant impression in which their delusion consists should be regarded not as an error, but as truth; in other words, their actions ought to be con- sidered as if they had been committed under the cir- cumstances under which the individual believed him- self to act." If the imaginary circumstances make no change as to the imputability of the crime, then they ought to have no effect on the case under con- sideration ; if they lessen or destroy culpability, they ought to have that effect in the supposed instance. The man is to be assumed to have a dual being—a sane and an insane personality ; and according as he acts in the former or in the latter capacity is to be condemned as a criminal or to be acquitted as a madman. Such is the criterion of responsibility which is founded on the metaphysics of insanity, and which commends itself to the approval of those who, like the eminent philosopher Kant, hold that the determination of the question in any case should be left to philosophers who have made the human mind their study, and not to physicians who have 226 RESPONSIBILITY IN MENTAL DISEASE. acquired a knowledge of the disease. It is fortunate in this matter, as in other matters, that physicians have devoted themselves to the patient observation of facts, instead of invoking their own minds to utter oracles to them, or accepting with reverence the confused oracles which other minds might utter to them. They would have known little of the na- ture of any disease or of the remedial action of any drugs at this day had they depended only upon what those who had studied the physiology of the body could tell them; and they would have known little of the nature of mental diseases and of their proper mode of treatment if they had depended only upon what those who had studied psychology could tell them. I have already pointed out that lawyers, in the importance which they assign to delusion as a mark of insanity, vastly overrate its value. Not half the insane acts of a person labouring 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 off- spring 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 re- sults of insane reasonings from insane premises, or of impulses which spring up in insane minds without being connected with the existing delu- sions. PARTIAL INSANITY. 227 Let me suppose a case in order the better to apprehend the doctrine which is legally propounded and the criticism to which it is open. An individ- ual believes himself to be Jesus Christ, but talks rationally on all matters unconnected with his de- lusions, and conducts his affairs with intelligence; nevertheless he one day suddenly shoots somebody, and in due course is put on his trial for murder. It cannot be shown that he did the deed under the influence of his delusion; moreover, if the imaginary circumstances were real, they would hardly absolve him from responsibility, seeing that it is not in accordance with the character of Jesus Christ to do murder, and seeing that a mad- man must theoretically be consistent with his char- acter ; he must therefore righteously be put to death as a criminal. Clearly the theoretical prin- ciple ill bears the test of practical application, for it is certain that, notwithstanding its foundations in metaphysical philosophy, in no civilized country in the world would such a person be executed as a murderer; and, as a matter of fact, the principle is frequently violated in practice while it continues to be upheld in theory. Assuredly this is a mischiev- ous thing, which cannot better be condemned than in the words used by Hoffbauer in reference to an- other matter:—" All legislation ought to be founded on a knowledge of the object to which it is applied. If this knowledge is defective, it would be much better that the law should not define at all than that it should make a bad definition, and introduce 228 RESPONSIBILITY IN MENTAL DISEASE. errors which, although contrary to its purpose, are perpetuated by its authority." The ordinary medical doctrine, which has been formulated as an induction from the practical ob- servation of insanity, is that this so-called mono- mania, or, as it is called by English jurists, partial insanity or partial delusion, excludes the idea of criminality, and takes from the affected person all responsibility for his actions, whether or not these are the results of the delusion under which he labours. Let us weigh the value of the opposing dogmata. In the first place, the legal dogma is* open to criticism from its own basis. It is not true that a person who has a delusion, and acts under it? influence, has necessarily lost his knowledge of right and wrong in the particular case, or the power to control his actions in relation to his delusion ; he may know quite well that what he does is contrary to law and will entail punishment, and the know! edge that other persons will consider it wrong and treat it as a crime may so far influence him as to prevent him from yielding to his own impulses. Nothing is more certain than that a monomaniac will sometimes conceal or deny his delusions, dis- semble his feelings, and regulate his conduct accord- ingly, when he has a strong motive to do so, whether this be a lively fear of suffering or a strong hope of gain : he is neither without knowledge nor without power of control. In truth, it might often be justly said of such an one acting under a delusion that, although his knowledge is more at fault, he has PARTIAL INSANITY. 229 greater power of control than the person who acts under a desperate insane impulse, and that he is, therefore, so far as culpability can be attached to madness, the more culpable of the two. The legal doctrine thus breaks down in its application to the cases which it is supposed to specially cover : it is " hoist with its own petard." If English jurists would be logical, they must insist on the propriety of hanging an insane person who does murder under the influence of delusion, unless it can be clearly shown that he did not know the act was wrong; the burden of proving the incapacitating degree of his insanity being laid upon the lunatic in this as in other cases. The medical doctrine, by which monomania is held to exclude crhninality, is founded mainly on the three following considerations : first, that a de- lusion may be concealed, wherefore it might be overlooked, although it had actually affected the conduct; secondly, that it is impossible to follow the workings of an unsound mind and to discrimi- nate between a healthy and a morbid action thereof, it being beyond dispute that an act which a looker- on cannot discover to have any manner of connec- tion with the delusion may still be the insanely logical outcome of it; and, thirdly, that it is im- possible to isolate an insane delusion and thus to prevent the infection of its morbid nature from spreading, it being certain that the whole disorder in monomania is not restricted to one delusive idea, that the rest of the mind is in a more or less marked 16 230 RESPONSIBILITY IN MENTAL DISEASE. state of moral or affective alienation—in a state, therefore, in which insane impulses to acts of vio- lence are likely to occur. The sum of the matter is that, in the condition called monomania, there is usually a much deeper and more general mental derangement than is supposed, and that it is im- possible, in estimating the cause of particular con- duct, so to isolate the operation of the partial insanity as to be able to say that the crime is unconnected with it. I shall say a few words on each of the above-mentioned considerations sepa- rately. {a) It would be easy to fill pages with stories ex- hibiting the extreme reticence which the insane sometimes display with regard to their delusions; but two or three instances will be enough. A com- missioner who was sent to Bicetre in order to set at liberty those whom he should judge to have recov- ered, examined an old vine-dresser who, in his re- plies to questions, gave no indication of madness and uttered no incoherent expressions. The order was prepared, according to form, for his release, to which he had to put his signature; he took the pen and wrote the name of " Christ." Esquirol attended a gentleman who had made several attempts to de- stroy himself; he would ask for a pistol to shoot himself, saying, " I am tired of life." He betrayed no illusion, and was generally cheerful. It was not until after two years that he confessed that he la- boured under hallucinations of sight and hearing: he believed himself to be pursued by officers of the PARTIAL INSANITY. 231 police; saw and heard them, as he thought, through the apertures of his apartment, the walls of which he asserted were made of panels so arranged that all he said and did might be perceived from without. Dr. Hood had under his care a patient who was placed in Bethlehem Hospital for having annoyed the Queen on one occasion in Rotten Row by pre- senting a petition to her praying for some place under Government, and who was detained there for twenty years. For the last fifteen years he was there he had shown no symptom of his particular form of insanity, and for the last eight years no symptom of insanity at all. After a very strong effort Dr. Hood obtained his discharge ; but he had not been gone five months before he was sent back to the hospital, having addressed three or four let- ters to the Queen asking for the hand of Princess Alice. Again, it is well known that some melan- cholic patients are so silent that it is only after their recovery we discover what their delusions really were, although these may have been of an extreme character, and may have dictated the most extraor- dinary conduct, and occasioned the most grievous suffering to themselves. How, then, is it possible in such cases to determine what actions are or are not in relation with the delusions ? Many times is the asylum-physician perplexed to divine what are the unexpressed delusions that are holding posses- sion of his patient's mind and governing his conduct. If he could always do so, his duties would be far less anxious than they are now; but he might take the 232 RESPONSIBILITY IN MENTAL DISEASE. most acute counsel of any court, place him before patients whose lives were under the sway of delu- sions, and defy him with all his skill in examination and cross-examination to elicit what those delusions were. If he himself can guess, it is only because his conjectures are informed by past experience. Many a gibing sneer and ill-timed jest at medical testimony in courts of justice would be spared if those who utter them so glibly were to spend a few months in an asylum, and thus to bring home to their minds the extraordinary inconsistencies and the startling inexplicabilities displayed in the thoughts, feelings, and acts of those who dwell therein. {b) Few who have heard the accounts which in- sane persons sometimes give of the motives which have influenced their acts would venture to say posi- tively that a particular act was unconnected with their known delusions, however independent of them it might seem to be. It is not true, in fact, that a madman reasons and acts logically from the false premiss of his delusion ; and it is monstrous in the- ory to assume that a belief which itself exists only in violation of all reason should conform in its ac- tion to laws which govern the action of, and are therefore appreciable by, a sound intelligence. If this were so, it would not be difficult to predict ex- actly from the character of his delusion what an in- sane person might do, and so to preclude mischief on all occasions. But the difficulty of their care, that which constitutes the chief anxiety in the man- PARTIAL INSANITY. 233 agement of them, is that, although we may know what they think, we cannot foretell what they will do; we may know full well their delusions, but we cannot follow the workings of them in their minds and foresee their outcome in action : there is an in- coherence between their ideas, and there is an inco- herence between their ideas and actions. Locke's well-known saying, that madmen reason correctly from false premises, is indeed far from true of all cases; they often reason insanely from insane prem- ises ; they do not do those things which, were their delusions true beliefs, they ought to do, and they do those things which, were their delusions true beliefs, they ought not to do, and there is no health of mind in them. Who, then, but a metaphysician adoring his theories and ignoring facts, would ven- ture to declare how far an act had been influenced by a delusion ? There is a well-known case, which has been quoted by writers on medical jurisprudence, of a young man affected with some degree of imbecility, who was of childish manners, and evinced a strong pro- pensity for windmills : he would go any distance to see a windmill, and would sit watching one for days together. His friends, hoping to do him good by a change of place, removed him to a part of the coun- try where there were no windmills. On one occa- sion he set fire to the house in which he was placed, and on another occasion he enticed a child into a wood, and, in attempting to murder it, cut and man- gled its limbs with a knife in a horrible manner. 234 RESPONSIBILITY IN MENTAL DISEASE. Before these outbreaks he had never shown any dangerous propensities. Had all the professors of logic and moral philosophy in the country been set to work to discover the motive of his dangerous acts, it is probable that they would have failed to do so. And yet it was very simple : he had done them in order that he might be removed to some place where there were windmills. From time to time I see a gentleman who has been confined for some years in an asylum, having been placed there as a criminal lunatic. For some time before he was put under restraint he had alarmed his friends by his conduct, had flourished a loaded revolver in the street, and had at last struck on the head with an axe a cab-horse as he drove past it. He was acquitted at his trial on the ground of insanity. He had at the time the delusion that he was Jesus Christ, but soon after he was placed in confinement he was calm and courteous in behav- iour, rational in conversation, and so sane apparent- ly that his wife made strong and repeated represen- tations to the authorities in order to obtain his discharge. On two occasions he was examined at her request by two eminent physicians, who could find no insanity in him, and strongly recommended his discharge. And yet this gentleman, as it ap- peared afterwards, believed all the while that he was Jesus Christ, and had made the attack on the cab- horse in consequence of that delusion: he wished by the publicity which he would thus gain to at- tract attention to his mission. Insane enough to PARTIAL INSANITY. 235 conceive and act upon such a motive he was still in- telligent enough to appear so sane as to deceive two physicians, who were informed what had been his delusion and what he had done. Given the act alone, could any one, however acute in the analysis of motives, have guessed the motive of it ? Given the delusion alone, could any one, however much experience of insanity he might have had, have pre- dicted the course of action pursued ? Given the delusion and the act, what sane mind could, without help from the patient—which for years he would not give—have made known the connection which actually existed between them ? On one occasion I spent an hour with this gentleman, endeavouring to elicit from him evidence of the delusion which I was sure he had, and an explanation of the motive of the act, which I was sure was an insane one. He was quiet and gentlemanly throughout the inter- view ; but although I was convinced of his derange- ment from his inability or unwillingness to give any rational explanation of what he had done, and from certain marks of what seemed weakness of mind, I was not able to elicit any fact which would have sufficed to found a certificate of insanity upon. I may say, however, in excuse of my failure, that he had for some years been living a quiet and regular life in an asylum, free from cares and excitement, and that there was reason to believe he had been schooled to conceal his delusion by those who were striving to obtain his discharge. It was the more remarkable that a person who was capable of so 236 RESPONSIBILITY IN MENTAL DISEASE. much self-control should ever have acted in so in- sane a manner, and from what, even were the delu- sion regarded as truth, must still be deemed so in- sane a motive. The example illustrates the absurdity of impos- ing on a sane mind the task of diving into the trou- bled depths of a lunatic's mind, and tracking the incoherencies of his disordered thoughts and feel- ings ; of tracing the connection between mental phenomena, the essential character of which is that they are not coherent, that they follow one another in no logical relation, not in an order but in a dis- order of association opposed to all the experience of sanity. If a sane person could succeed in doing this it could be only on one condition—namely, that he should become as insane as the person whose mind he was studying: in that wxay only could he follow and appreciate its insane reasonings. The delusion is not itself the disease, it is only a striking symptom of the disease; and it is certain that the criminal act may be a manifestation of the disease of which the delusion is a symptom, and that no connection between them may be detectable by a looker-on, notwithstanding the existence of a real pathological connection. (c) When an insane delusion exists in the mind, however circumscribed the range of its action may seem to be, the rest of the mind is certainly not sound; on the contrary, it is in a condition in which not only do impulses that are in relation with the delusion acquire an irresistible force, but in which PARTIAL INSANITY. 237 unaccountable impulses spring up without relation to it. Outside the recognised circle of morbid ideas there will be found, if a sufficiently careful examina- tion be made by a competent person who knows the individual or knows the disease, evidence of mental disorder—evidence of such loss or perversion of natural feelings, such change of character and habits, such excitability of disposition, with loss of self-control, and such weakening of mind, as con- stitute a general alienation apart from the particular delusions. He is centred in himself, and it is a morbid self; social feelings wane or are extin- guished ; his intelligence is so far weakened that what he perceives at once to be the grossest folly in another, he cannot perceive to be any folly in him- self ; if he be sent to an asylum, it is extraordinary how little able he seems to be to realise why he is there, and, in some instances, what a strangely im- perfect appreciation he shows of the derangement of other inmates. His delusions, which are the out- growth of an exaggerated egoism, drain into them- selves the energy or vitality of all his mental pro- cesses; his mind is not unsound upon one point, but an unsound mind expresses itself in a particular morbid action. An insane delusion will not spring up and grow in an unsuitable soil, and the soil which is suited to it is insanity: let that soil be changed to one of sanity—in other words, let the mind apart from the delusion be sound, and this will dwindle and die. If a so-called monomaniac has the delu- sion that his wife, whom he has hitherto loved and 238 RESPONSIBILITY IN MENTAL DISEASE. trusted entirely, is dishonouring or conspiring against him, the existence of a delusion so foreign to the whole habit of his healthy thought and feeling marks a deeper and more general derangement of mind, and it is impossible to foresee the extent of its possible influence upon his conduct. At a meeting of the Societe Medico-Psycho- logique of Paris in 1872, Dr. Foville gave some interestmg information as to the effects of the war upon certain patients who were labouring under a partial delirium, having delusions of persecution, and who would commonly be called monomaniacs. One patient who read the newspapers regularly, and appeared to follow all the events in a very in- telligent manner, affirmed that he was not fool enough to accept as real either the accounts which he read or the incessant discharge of artillery which he heard; that all the noise which he heard was produced by some fools who pretended to fire the cannon to amuse themselves, but whose real end was to cause him to lose all patience, and to have a pre- text for causing him to perish of hunger by reduc- ing more and more the allowance of food. Another patient repeated daily that the pretended war was only a comedy, all the scenes of which had been previously arranged between the Prussians and French; that the guns and cannons were only loaded with powder; and that all reports as to the number of killed and wounded were pure invention. Doubtless many people were caught with the farce, but he was not one of them. A more remarkable PARTIAL INSANITY. 239 case still was that of a captain of the Imperial Guard, who wras admitted into Charenton some weeks only before the declaration of war, and who laboured under delusions of persecution. It might have been expected from his profession, from his having numerous relatives in the army, from his comparative lucidness—which on many subjects was perfect—that he would have been most interested in the military events, and would have followed the disasters of the war with the greatest attention. But it was exactly the opposite. All the defeats and sieges of the war, the fall of the Empire, the invest- ment of Paris, the conflicts before it, various episodes of which he saw with his own eyes, the bombard- ment of the forts, which he heard incessantly, the capitulation of Paris and its deplorable consequences —all were to him as if they had never happened. Each event was related to him by several people, but he would not believe a word of what he was told; all means were employed to convince him, but without success; he resisted all arguments, re- plying to them by taking exception to them or by systematic denial. He never ceased to maintain that France was at peace, the Emperor at the Tuileries, that all means of communication were open, and that the authorities of the asylum made common cause with his persecutors by refusing to forward his letters to his relatives, and by with- holding their answers to him; that all the noise made about the house by the cannonading was the work of some officers of his regiment—his open 240 RESPONSIBILITY IN MENTAL DISEASE. enemies, who were bent upon annoying him, and whom he mentioned by name. One day he was shown five or six different newspapers, all of them of the same date, relating to the same facts; he read them with the same incredulity, maintain- ing that they were all sham newspapers, printed for him alone by his persecutors, so determined were they not to desist, cost them what it might. Certainly, as Foville observes, these facts are of a nature to shake very strongly the theory according to which, through the mutual independence of the faculties, there is supposed to be but a partial lesion of them in monomania, without a general alteration in their harmony. No one could believe, unless he was convinced by experience, how great and general may be the loss of power of appreciation, the im- pairment of intelligence, and the lesion of judgment manifested by insane persons who appear rational on all save one or two subjects ; in no case can we predict how much madness the application of a suf- ficient test may discover ; we can predict only that it will elicit a great deal more than appears on the Burface. Nor will the evidence of it be wanting in his conduct: inside an asylum, where his life is regular and monotonous, the so-called monomaniac may go on calmly from day to day, doing the simple duties set before him ; but if he be left to his own devices in the world, and especially if he be placed under conditions which impose a strain upon his mental resources, impulses of which neither he nor any one else can give a rational explanation are apt PARTIAL INSANITY. 241 to arise in his mind and to realise themselves in his conduct. In order to form a conception of the nature of these frantic impulses, we must compare them with convulsive movements, which are the expressions of a morbid condition in the motor-centres similar to that from which they originate in the mind-centres. Both in physiological and pathological actions we have instances of movements which take place in what is called sympathy with others, without having a manifest connection with them; as, for example, the useless contortions of the facial muscles which are so marked in some persons when making a mus- cular exertion, and certain convulsive movements which, accompanying other directly caused convul- sions, we describe as sympathetically excited. They occur together, although we do not see why they should do so, just as in like manner sensations ex- cited in one part of the body will sometimes occa- sion sensations in another part, without our being able to assign a reason for the concomitance ; for to call them sympathetic is not an explanation; it is merely to use a general name to bind together and denote a class of phenomena which, occurring to- gether, we cannot at present explain the connection of. The lesson which they teach us may, however, be profitably applied to the study of the function of the higher nerve-centres—those which minister to mind : an active morbid idea in the mind may ex- cite into activity another idea which has no discover- able relation to it in consciousness, and this last may 242 RESPONSIBILITY IN MENTAL DISEASE. realise itself in some deed, which, so far as the pri- mary idea is concerned, seems inexplicable; there may, in fact, be a synergy of idea, as there is nota- bly a synergy of movement, or a sympathy of sen- sation. A poor woman, the mother of two children, became depressed, and fancied that she was perse- cuted ; she was also suicidal, but went about her daily duties with regularity. One day, however, without seeming anywise different from usual, she seized one of her children, and beat its head against the floor until it was dead; and she would have done the same with the other child had she not been pre- vented. She was sent to an asylum, where she re- covered after a time; but she never could tell how it was that she had killed her child, when she was so fond of it. The case is one .of a class of cases in which frightful impulses spring up in the diseased mind, and drive the individual to a deed of violence ; they may be as little within control as are the convulsions of epilepsy, and the origin of them perhaps as little within the individual's knowledge as the origin of the impulse which entered the unfortunate herd of swine, and drove them over a steep place into the sea, so that they were drowned, was within their knowledge. The right problem for a court of jus- tice to place before a scientific witness is to trace a connection not between the delusion and the act, which may be undetectable—or, if detectable, such as would not excuse the act if the delusion were true—but between the disease and the act. Cer- PARTIAL INSANITY. 243 tainly, it is an extraordinary demand to make, that when two symptoms of disease exist, the delusion and the criminal act, the one should be proved to be the cause of the other ; that the effects of a common cause should be proved to be cause and effect. Out of the depths of deranged feeling in which the delusion is rooted there may spring up at any mo- ment insane impulses, which are quite independent of it, but which, like it, are born of the disease. Thus much, then, with regard to the cases of homicidal insanity in which there is a distinct de- lusion and the homicide has or has not an evident connection with it. In the next chapter I shall say something specially of homicide in connection with epilepsy. CHAPTER VII. EPILEPTIC INSANITY. Mania following epilepsy: its furious character—Masked epi- lepsy—Mental disorder preceding the epileptic attack— Epileptiform neurosis manifesting itself in periodical at- tacks 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-hallu- cinations after waking from sleep. When a murder has been committed without apparent motive, and the reason of it seems inex- plicable, it may chance that the perpetrator is found on inquiry to be afflicted with epilepsy. It is an important question, then, how far the existence of this disease affects his responsibility. At the outset we may declare unhesitatingly that an epileptic per- son may be quite as sane as one who is not so af- flicted, and, in the event of his doing murder, quite as responsible; though his passions are more vio- lent, in the intervals between the fits there may be 244 EPILEPTIC INSANITY. 245 nothing to warrant the slightest suspicion of any mental disorder. But it is an undoubted effect of epilepsy in some instances, as the experience of every asylum testifies, to produce mental derange- ment of a furious kind; and the nearer we get to the fit, the more reason is there to suspect that the mind may have been affected; wherefore an old author, Zacchias, declared that every epileptic ought to be regarded as irresponsible for acts committed by him within three days before or after an epilep- tic attack. Without subscribing to this arbitrary limit, we certainly ought to scrutinise closely the forms of mental disorder which, occurring immedi- ately before or after an attack, have led to the enunciation of such an opinion. What happens frequently in asylum epileptics is this: that after a fit, or a succession of fits, there follows a brief attack of furious mania, which is known as epileptic mania. On account of its vio- lent and destructive character, it is a most danger- ous form of insanity ; for the patient, in a frenzy of excitement, unconscious of what he is doing, his senses perhaps possessed with frightful hallucina- tions, is driven to most destructive acts of violence against both animate and inanimate objects. After the excitement has lasted for a few days, or it may be only a few hours or a few minutes, it subsides, and the person comes to himself ; if he has injured or killed some one in his fury, he realises for the first time what he has done. During the intervals between these epileptic and maniacal paroxysms, 17 246 RESPONSIBILITY IN MENTAL DISEASE. which may be intervals of weeks or months, he is calm and sensible; there may be no mental impair- ment whatever at first, although after the disease has lasted for some time there will be loss of mem- ory and weakness of mind, deepening into actual dementia in the worst cases. It is one of the sad- dest experiences of asylum life to witness the pitiful fate of those patients who have not sunk below the consciousness of their condition. Gentle, amiable, and industrious through their long intervals of lu- cidity, they hope against hope that each recurring paroxysm will be the last; they eagerly try all remedies, in the hope of curing the disease; they see others leave the asylum restored to health, and confidently anticipate that their turn will also come; but confidence wanes as the attacks recur, the mind is slowly weakened by the storms of fury through which it passes, and they sink finally into the apathy of dementia—a state of mere oblivion, in which they cease to hope or care more. This is one form of epileptic insanity in which homicide is sometimes done. When the disease has been so well established that it has been found necessary to send the patient to an asylum, there will be no difficulty in recognising its nature, but when the mania follows the epileptic attack for the first time, and especially when it passes off after lasting for a few hours only, it is obvious that it might easily be overlooked. If the unfortunate sufferer has killed some one under these circum- stances, and has not chanced to come under the ob- EPILEPTIC INSANITY. 217 servation of a skilled observer, it may go hard with him when he is put on his trial for murder. The character of the deed itself in such case may have the greatest significance; if it has been done with great violence, without indications of premeditation, without apparent motive, and without secrecy, and if the accused person is discovered to be the victim of epilepsy, it is probable that it has been done in a paroxysm following an epileptic fit. A second form of epileptic insanity in which homicide is sometimes done is really a masked epi- lepsy ; a transitory mania occurring in lieu of the usual convulsions. Instead of the morbid action affecting the motor centres and issuing in a parox- ysm of convulsions, it fixes upon the mind-centres and issues in a paroxysm of mania, which is, so to speak, an epilepsy of mind. Many cases of so-called transitory mania {mania transitoria) are really cases of this kind—cases of mental epilepsy. Both forms of mania may occur in the same patient at different times: his fits may be followed by mania, as is most often the case, or he may now and then have a maniacal taking the place of an epileptic paroxysm. Thus, in one case of epilepsy complicated with mania there were three kinds of symptoms at different times: (1)—Epilepsy pure and simple ; (2) Epilepsy followed by violent delirium, chiefly of action, in which the patient tumbled about on the ground in an extraordinary manner with great rapidity without speaking a word, this condition, during which intel- ligence and sensibility were abolished, lasting for 248 RESPONSIBILITY IN MENTAL DISEASE. ten minutes; (3) An attack of mania without epi- lepsy, the patient falling, after the excitement, into an almost ecstatic state, from which he returned slow- ly to reason. Between these attacks he was quite sensible. The practical lesson which cases of this kind teach is, that in the event of homicide we must not insist on its being proved in every case that actual convulsions had occurred; for the instance may be one of masked epilepsy. A third form of mental disorder occurring in connection with epilepsy, and marked sometimes by a homicidal outbreak, is that which is observed now and then before the fits come on. Before their access a notable change often takes place in the character of the asylum-epileptic : instead of being, as he usually is, amiable and gentle, he becomes sus- picious, sullen, and surly, and whereas he is gener- ally ready to talk cheerfully, he will not answer at all, if addressed, or will answer shortly and surlily, or may answer with a blow ; he displays uncontrollable anger with or without some slight cause, and reckless violence; the most indifferent question or remark, or the slightest accidental touch, may cause an outbreak of the extremest fury; wherefore he is, if much in- terfered with, most dangerous to others. With this condition of profound moral perversion, delusions of suspicion and hallucination of a vivid nature may or may not be associated : if he sets fire to a house, or kills some one, or does some other act of violence, it is either that he is overwhelmed with such a vague, vast, and painful feeling of mingled fear and appre- EPILEPTIC INSANITY. 249 hension, that he must find relief in convulsive action, or that he acts under the influence of some hallucination or delusion, or there may be a com- bination of these mental states. In due course the fits occur, the cloud of disordered feeling passes from the mind, suspicions and delusions disappear, and, after a short period of mental confusion and stupor, he returns to his amiable and gentle state, remaining so until an exactly similar moral change foretells the approach of the fits on another occa- sion. As an illustration of the danger of this kind of mental disorder take the following case:—A patient, aged thirty years, confined in the French asylum at Avignon, wras subject to severe epileptic fits from time to time. On one occasion after an attack he threw himself out of the window; on another occa- sion he seemed exhausted and desired to embrace his father, whom, but for help given, he would have strangled ; on other occasions he was maniacal, and would kill everybody who came near him. In the intervals between the attacks he was sensible, pleas- ant, and amiable, though a little vain, as is common with such patients, and considering himself superior to the other inmates. He was attached to the Super- intendent, who granted him indulgences, and for whom he worked willingly. Towards the end of March he had a succession of epileptic fits for two or three days, which were followed by incoherence, hallucinations, and great excitement. At the begin- ning of April he had a single fit. On the 21st of 250 RESPONSIBILITY IN MENTAL DISEASE. the month he held out his hand to the Superintend- ent whom he met, and uttered the word " Union," but otherwise exhibited no difference from his or- dinary state. Next day he was still calm, but sombre. On the 23rd he was standing in a passage as the Su- perintendent passed; he pretended to have a pain in the leg, and as the latter stooped down to examine it, he stabbed him violently to the heart with a pair of scissors, so that death took place in an hour and a half afterwards. In the following night he had an epileptic attack. When questioned about what he had done, he said that for some nights he had heard the voices of the members of a secret society, telling him that if he did not kill the Superintend- ent he would be miserable all his life. He had uttered the word " Union " to ascertain whether the Superintendent had any connection with these voices and belonged to the secret society. After the fatal act the epileptic attacks were more frequent for some time, the mental disorder was greater, and the lucid intervals were rarer and shorter, but during them he was sorry for what he had done. Lastly, let me note that epileptic insanity, mani- festing itself chiefly by irritability, suspicion, mo- roseness, and perversion of character, with peri- odical exacerbations of excitement, in which vicious or criminal acts are perpetrated, showing itself, in fact, in a profound moral or affective derangement, may occur periodically from time to time for months or even years before distinct epileptic fits declare themselves, these at last making their appearance, EPILEPTIC INSANITY. 251 and supplying the interpretation of the previously obscure attacks of recurrent derangement. Morel has pointed out that some cases of homicidal and suicidal mania are really cases of this kind in which an epileptiform neurosis has existed for a long time in an undeveloped or masked form. But as such attacks may occur periodically for some time before the access of genuine epilepsy, so may they also oc- cur periodically for some time after it has ceased. Falret mentions one case in which, after epilepsy had ceased for twenty-one years, a strong impulse to homicide, which necessitated restraint, displayed itself. I shall not, however, multiply examples, but content myself with the following instances:—A man, aged sixty-two, had in his youth been subject to epilepsy, and had been discharged from the mili- tary service in consequence. After this the attacks gradually became more rare, and they finally ceased; none having been observed for forty years. There was nothing particular noticeable in him except an inclination for good living and a condition of exal- tation in the spring. One day he suddenly stabbed bis aged mother in the throat several times, and when she fell down he sat upon the body and stabbed her repeatedly. When he was seized, he exclaimed, " She is a villain who has done me all the injury possible ; I ought to have killed her long ago." There was no discoverable motive for the crime; but it appeared that for several years dur- ing his periods of exaltation in the spring he had reviled his mother, and threatened to kill her; and 252 RESPONSIBILITY IN MENTAL DISEASE. the date of the murder corresponded with the period of exaltation. A more striking case still is one related by Es- quirol. A Swabian peasant, aged twenty-seven years, whose parents did not enjoy the best health, had been subject to epileptic fits from his eighth to his twenty-fifth year. But the character of his dis- ease then underwent a change ; in place of epileptic convulsions, the man found himself seized with an irresistible impulse to commit murder. He felt the approach of the homicidal paroxysm for several hours, and sometimes for a day, before it came on, and then earnestly begged to be bound, lest he should commit a crime. " When it seizes me," he said, " I must kill some one, were it only an infant." His mother and father, whom he loved dearly, were the first victims of these fits : " Mother," he cried in a loud voice, "save yourself, or I must strangle you." Before the attack he was greatly exhausted, had slight convulsive movements in the limbs, and was overpowered with a feeling of sleep, without being able to go to sleep. During the paroxysm, which lasted one or two days, he retained conscious- ness, and knew perfectly that if he committed mur- der he would be guilty of a crime; and when he was put under restraint, he made contortions and frightful grimaces, sometimes singing, and sometimes speaking in rhymes. When it was over, he cried, " Unloose me. Alas! I have suffered greatly ; but I am well out of it, since I have killed no one." * * Other similar cases in which the cessation of epileptic fits EPILEPTIC INSANITY. 253 Having thus briefly set forth the varying order of events in epilepsy complicated with mental dis- turbance, I shall now go on to say something more in detail of the character of the mental symptoms. They may be described under four divisions,—the first including those which sometimes go before an attack of epilepsy, and are known as its prodromata or forerunners; the second division including those which, corresponding in the mental sphere with those slighter forms of epilepsy that are known as epileptic vertigo, or the petit mal, Falret describes as a sort of petit mal; the third including the more violent symptoms which would correspond to the regular epileptic convulsions, or the so-called grand mal; and the fourth including those symptoms of mental decay which follow long-continued epilepsy, and mark what is called epileptic dementia. First, then, with regard to the mental prodro- mata of epilepsy. As I have already said, some persons become morose, surly, irritable, and quarrel- some ; others exhibit great dulness of conception, enfeebled memory, confusion of ideas—in fact, a physical and mental dulness or torpor; others, on the other hand, display an unwonted gaiety, loquaci- ty, and self-confidence, which contrast strangely with their usual dull and apathetic state. It has been pointed out by Falret that in some cases the same ideas, the same recollections, or the same hallu- was followed by attacks of mental epilepsy are related by Dr Echeverria in a recent article on " Epileptic Insanity," in the American Journal of Insanity for July, 1873. 254 RESPONSIBILITY IN MENTAL DISEASE. cinations recur before the attack ; that on each oc- casion the person has the same vivid mental im- pression, or sees the same spectral illusions, or smells the same odour, or hears the same voice uttering the same words ; and it is curious enough that the recurring idea or image is sometimes a reproduction of that which went before, and perhaps provoked, the first attack. We may liken it to the strange sen- sation which, occurring in some part of the body immediately before the loss of consciousness and the convulsions, is known as the aura epileptica. It is certain, then, that there are in many cases of epilepsy mental disturbances which, though we may call them prodromata, are really a part of the at- tack ; and it is not a little strange, having regard to these and similar facts, that any one should ever have placed the morbid seat of epilepsy in the central or in the lower ganglia of the brain. The ordinary epileptic loses consciousness before he falls down in convulsions; it would therefore seem that his supreme cerebral centres are in trouble before the storm affects the lower centres. 2. It is well known that there are some attacks of epilepsy which may be described as abortive or incomplete. There are no convulsions, nor does there appear to be a complete loss of consciousness; the person utters a few unintelligible words, or makes some incomprehensible sounds, or he may exhibit indications of a profound but momentary terror, with or without grimaces or other slight muscular spasms, and then is himself again, quite EPILEPTIC INSANITY. 255 unconscious of what has happened to him. A re- markable circumstance which has occasionally been observed in connection with these incomplete at- tacks is that, after the individual appears completely restored to himself, and speaks and acts as if he were so, the attack recurs, and when it has passed off and he is really himself, he remembers nothing of what he said and did in the interval of seeming lucidity ; and yet this normal or apparently normal state of reason, in which he answers questions, makes remarks, and does various acts, may last for hours or even days. He may be likened to a person in a dream who, being awakened out of it, talks sensibly with some one for a short time, soon goes to sleep again, continues his interrupted dream, and, on awakening finally, has no memory of the interval during which he talked. I have spoken of the intervening state of lucidity as a normal or apparently normal state, and such it certainly seems to be in some cases, so like his nat- ural self does the individual appear; but in other cases it is plain that, although he converses and acts as if he were quite conscious and master of himself, he is nevertheless not really in his normal state of mind ; he exhibits a loss of perception, more or less confusion of ideas or incoherence of language, or even actual delusions, and does strange or foolish things which indicate some degree of mental aber- ration. Like the somnambulist, he only perceives the objects which affect his senses in so far as they are connected with the ideas and feelings which 256 RESPONSIBILITY IN MENTAL DISEASE. hold possession of his mind, or perceives them in the form and colour which his ideas and feelings impart to them. These peculiar states of epileptic consciousness are not only of great psychological interest, but also of practical consequence in relation to the question of responsibility; for it is obvious that deeds might be done by an individual when in the anomalous state of consciousness, of which he might have no remembrance when in his really normal state, and for which, therefore, he could not justly be deemed fully accountable.* It is difficult for a healthy mind to realise such a pathological state of consciousness : in order to do so, or rather—as it must be impossible to truly real- ise it except on the condition of the sound mind becoming unsound—in order to form an approxi- mate conception of it, it is necessary to draw conclusions, not from the experiences of self-con- sciousness, but from observation of those abnormal conditions of consciousness which are manifested in insanity, in somnambulism, in the hypnotic or so- called mesmeric state, and in certain dreams, where the individual evinces some perception of things around, and acts as an apparently voluntary agent, while he is clearly living in an internal world, and is cut off by his mental state from anything like an adequate appreciation of his relations to his sur- * Dr. Echeverria discusses these conditions in an article on " Violence and Unconscious State of Epileptics in their relation to Medical Jurisprudence," in the American Journal of Insanity for April, 1873. EPILEPTIC INSANITY. 257 roundings. Some writers are in the habit of de- scribing these anomalous states of consciousness as states of unconsciousness, moved thereto probably by the metaphysical notion of consciousness as a definite invariable entity which must either be or not be; but this is obviously a misuse of words; and what it behoves us to learn from them is that consciousness is not a constant quantity, but a con- dition of mind subject to manifold variations both of degree and kind. The form of mental disorder which corresponds to the petit mal or epileptic vertigo may be described as a great confusion of ideas accompanied often by instantaneous impulses to violence. Those afflicted by it become sad and morose without any cause in external circumstances; are profoundly distressed, and exhibit much irritation against those who are about them; suffer from loss of memory and dul- ness of intelligence, so that they cannot collect and fix their thoughts; feel sadly that they are no longer themselves, that they are impelled to strange or vio- lent acts by a power which they cannot resist; op- pressed by a vague anxiety or dread, they leave their homes and wander about the streets or the country; all the painful ideas which they have conceived at different periods of their lives come back and fasten upon their minds; they are overwhelmed with a vague anxiety and terror. In this state of confusion and distress they accuse their friends of hostility, and imagine persecutions which have no existence out of their morbid fancies; and they do unlawful 258 RESPONSIBILITY IN MENTAL DISEASE. deeds, such as theft, incendiarism, suicide, or homi- cide ; some relieving themselves by destroying in- animate objects, others killing themselves in order to get rid of their anxieties and fears, and others at- tacking, in a blind and desperate manner, persons whom they chance to meet when their terror and distress have rendered their impulses uncontrollable. The deed of violence done, either there is immediate relief, the indefinable anxiety and confusion of ideas disappearing, and they recognize what they have done; or they continue in a state of excitement, unconscious, or very imperfectly conscious, of the gravity of their acts. When they come to them- selves, their memory is uncertain and confused, like that of a person awaking from a terrible nightmare ; they may remember the facts in a fragmentary way when they are recalled to their minds, or may deny them altogether. Let him who would realize, so far as it can be done by a sane mind, the mental state of these afflicted beings, try to recollect the most painful dream which he ever had ; let him reflect on its grotesque inconsistencies, the blest relief which he experienced when he awoke and found it was a dream, the fragmentary remembrance which he re- tained of it, and the little desire which he had to live it over again in memory; let him then suppose it to be no dream, but conceive himself to be over- whelmed by the horrible nightmare day after day, and to be, as he surely would be, incapable of even the hope of relief; what cry would then suffice to express his agony and despair save the cry of su- EPILEPTIC INSANITY. 259 preme agony, " My God, my God, why hast thou forsaken me ? "—what act save an act of suicide ? 3. Another form of epileptic mania is of a furi- ous character throughout its course, and may be compared in the mental sphere with the so-called grand mal or genuine epileptic convulsions. It differs from other forms of mania in its sudden in- vasion ; either there are no premonitory symptoms, or they occur only a few hours before the attack. They are headache, redness and brilliancy of the eyes, alteration of voice, slight convulsive move- ments of face or limbs, or sadness, irritability, and slight excitement. A second character, which is common to other forms of recurrent mania, is the close resemblance of one attack to another in its prodromata, symptoms, course, and termination; the same ideas, the same words, the same acts, are ob- served on each occasion; the attacks are almost as much alike as one epileptic fit is like another. An- other character is the extreme violence of the mania, which makes those who suffer from it the terror and danger of an asylum. There are frequent halluci- nations of the senses : threatening voices in the ears, overpowering odours in the nostrils, flames of fire or the redness of blood before the eyes. Terrifying ideas have possession of their minds; they see in those around them assassins who threaten their lives; and their fury is uncontrollable. Nevertheless, it is remarkable, considering their extreme fury, that their words are much less incoherent usually than those of other insane persons who are equally ex- 260 RESPONSIBILITY IN MENTAL DISEASE. cited; they comprehend and reply to questions more directly, and are more conscious of their surround- ings ; and yet, in singular contrast with this feature, they exhibit an almost complete loss of nlemory of the attack after it has passed off. The mania is usually of short duration, lasting only for a few days, and sometimes only for a few hours, and ceases as suddenly as it came on; there is perhaps a short period of torpor, and the person is himself again, without remembering clearly, if he remember at all, what has happened. Between this form of general mania and the previously described form of partial mania it should be understood that there is every degree of variation exhibited in different cases. 4. Lastly, the result of long-continued epilepsy is to impair and weaken the mind, producing, first, failure of memory, and ultimately a condition of dementia. In some instances this impairment affects principally, at any rate at the commencement, the moral faculties, giving rise to a state of moral im- becility or insanity; but, in the end, both moral and intellectual faculties are involved in a common ruin. Outbreaks of great maniacal excitement continue to occur from time to time in these cases. The classes of symptoms which I have thus briefly described include those which most com- monly occur in connection with epilepsy, but it must not be supposed that other forms of mental disorder are not sometimes met with in connection with it; there is hardly a form of mental derange- ment that has not been found associated with it in EPILEPTIC INSANITY. 261 occasional instances. A feature which is often very notable in epileptics is an exaggerated development of the religious sentiment, whereby it comes to pass that they see visions, and perhaps announce them- selves as the organs of special revelations from on high.* Like Swedenborg, they are sometimes car- ried up into heaven while yet in the flesh, and have conferences with angels, prophets, and even with the Supreme; or, like Mahomet, they are visited by angels, and are invested with a prophetic mission. Their visions, in fact, resemble very closely those which are said to have been seen by certain religious enthusiasts, and which have been the origin of cer- tain religious creeds.f It will be the interesting work of a future inductive psychology to examine and point out how many supposed revelations of the supernatural, and how many theological beliefs founded on such revelations, have been the results of deranged nervous function—a deranged mental- ism, if I may be permitted to coin such a word—of an epileptic or allied nature. * There is an interesting paper on " The Religious Sentiment in Epileptics," by James C. Howden, M. D., in the Journal of Mental Science for January, 1873. f An interesting chapter might be written upon the mental characteristics of the epileptic neurosis. There is the immense energy, such as was exemplified in Mahomet, Napoleon, &c. Then there is a singularly vivid imagination, which is apt some- times to occupy itself with painful or repulsive subjects. Prob- ably the invention of the modern sensational novel, with its murders, bigamies, and other crimes, was an achievement of the epileptic imagination. 18 262 RESPONSIBILITY IN MENTAL DISEASE. It is important to bear in mind that the existence of epilepsy may be overlooked for some time in a person even by medical men, and this is perhaps more likely to be the case when there is a mental alienation which absorbs the attention. Attacks of epileptic vertigo are sometimes so slight that they are thought to be merely transient attacks of giddi- ness or faintness; and it is notorious that patients labouring under them will often seek advice on ac- count of some ailment which they attribute to the stomach or the liver, the real nature of their malady only being elicited by accident, or by questions aimed to discover what is suspected. Another reason why epilepsy is overlooked is because the attacks often occur in the night only, and the per- son may then be unaware that he has had them. These things considered, it is extremely probable that many cases of so-called transitory mania might, if a careful enough examination were made, be found to be connected with epilepsy in some form or other. Delasiauve, who has insisted much on the frequency with which epilepsy exists undetected, relates the following instance :—H., who had been committed to the Bicetre, was re-admitted after murdering his mother. At the trial he had been acquitted on the ground of insanity. Epilepsy had not been suspected in his case ; and at the asylum he displayed complete lucidity, with the exception of short occasional excitements, up to his death, which occurred not long after his return to the asylum. Certain circumstances, however, led M. Delasiauve EPILEPTIC INSANITY. 263 to suspect epilepsy, and on inquiry he was able to trace his temporary aberrations, and therefore his overt acts, to previous nocturnal fits. He mentions another case of a young man, well bred, educated, and belonging to a respectable family, who was sent to prison for stealing. From prison he was transferred to the Bicetre on account of repeated epileptic fits. It was then ascertained that he had been subject to epilepsy for years, and it became evident that the theft had been the result of mental disorder connected with the disease. He manifested two quite different natures. The one was limited to about a week before and after the fits, when he was irritable, gloomy, intemperate, prone to violence, and capable of every imaginable mischief. It was mainly at this time that, while preserving sufficient lucidity to execute intentionally an act, he failed in the necessary discernment to judge of its morality, as also in the necessary self- control to abstain from doing it. During the other condition, which was the normal one, his character was quite a contrast; it was that of a man in the full possession of his senses, and free from any ex- travagance. Sometimes in place of this moral in- sanity there was an attack of incoherent and furious mania. What shall be said of the philosophy which would acknowledge the intellectual mania to be the result of disease, and yet declare the moral mania to be nothing more than depravity ? It cannot be said that there are special features so distinctly marking an epileptic homicide as to 264 RESPONSIBILITY IN MENTAL DISEASE. enable us to identify it on every occasion; but those which will commonly be observed are an absence of intelligible motive, an absence of premeditation, great determination and ferocity in the execution, much more violence than necessary being used, an absence of secrecy in the execution or of conceal- ment afterwards, a great indifference and absence of remorse, and an incomplete and fragmentary remembrance of all the circumstances, if not a complete forgetfulness of them.* Certainly, when a murderer lies down quietly to sleep by the side of the person whom he has just killed, we may safely predicate something abnormal in his condition; and seeing that a heavy sleep usually follows the epilep- tic paroxysm, the probability is that the act was the outcome of the epileptic neurosis. It must not be supposed that the absence of motive and of pre- meditation which I have mentioned as features of epileptic homicide will be observed in all cases; though common, they are not constant. An insane epileptic may go about his work of murder deliber- ately and under the influence of a feeling of revenge or jealousy. He is not emancipated by his two- fold disease from the ordinary evil passions of envy, hatred, malice, and jealousy; but, in estimating his * " Whenever we meet with isolated acts of violence, out- rages to persons, homicide, suicide, arson, which nothing seems to have instigated, and when, upon attentive examination and thorough inquiry, we find a loss of memory after the perpetra- tion of the act, with a periodicity in the recurrence of the same act, and a brief duration, we may diagnose larval epilepsy."— J. Farlet, Annal Med. Psyc., p. 1G2, Jan., 1873. EPILEPTIC INSANITY. 265 accountability, it is not right to permit the evil pas- sions to engage all our attention, and to forget that it is an insane person who is under their influence, and that they may be delusive morbid feelings, if they are not actually the cause or the offspring of the delusive ideas. We are in much need of a term to denote insane feelings, which shall carry as dis- tinct a meaning in the moral sphere, convey as defi- nite a notion of mental derangement, as does the word delusion when applied to an insane idea. De- lusion is a term which is understood by lawyers to mark insanity: who will help their understand- ings by the invention of a term which, applied to the more fundamental conditions of insane feeling and insane will, shall enable them to realise and talk of such states ? The right word is always a power; it gives definiteness to conception, and makes action more clear ; and it would make a mighty difference if the fit word to denote insane feeling could be found and take its place in the vocabulary. Although epilepsy, masked or overt, will, I think, be found to be at the bottom of most cases of mania transitoria, it must be admitted that there are some cases in which there is no evidence of epilepsy in any of its forms to be found; but it may well be doubted whether a distinct insane neurosis is not always present in these cases. With such a consti • tutional predisposition, a genuine attack of acute insanity, lasting for a few hours only, or for a few days, may break out on the occasion of a suitable exciting cause, and during the paroxysm homicidal 266 RESPONSIBILITY IN MENTAL DISEASE. or other violence may be perpetrated. After child- birth it sometimes happens that a woman is seized with a paroxysm of acute mania of short duration, during which perhaps she kills her child without knowing what she is doing. The effect of alcoholic intemperance upon a person strongly predisposed to insanity, or upon one whom a former attack has left predisposed to a second, is sometimes a short but acute mania of violent character with vivid hal- lucinations and destructive tendencies; and a like effect may be produced by powerful moral causes, sexual excitement, and other recognised causes of insanity. On one occasion I was summoned late at night in haste to see a young woman who was in a state of acute, violent, and incoherent mania, the whole household being in the utmost dismay. She had gone to bed complaining of nothing more than a loss of appetite and a feeling of bodily illness, and the outbreak of mental disorder was quite sudden. Suitable treatment was adopted, and in the morn- ing the excitement had passed off, some confusion of mind only remaining: she slept heavily during the day, and was soon herself again. Even in young children such paroxysms have been observed. Mo- rel records two cases in which children, one of them being ten years and a half old, the other only five years old, fell into convulsions and lost the use of speech in consequence of a great fright; after- wards a maniacal fury with destructive tendencies and continual turbulence occurred; in one case epi- lepsy followed, but in the other it did not. He also EPILEPTIC INSANITY. 267 gives an account of a girl, aged eleven years, who had furious maniacal attacks, during which she at- tempted to kill her mother and injure her sisters, and who finally recovered. Other instances of a similar kind might be men- tioned, but these will suffice to illustrate the fact that a transitory mania, accompanied by homicidal and other destructive impulses, may be produced by a sufficient exciting cause in a person who has a dis- tinct insane neurosis, just as epileptic convulsions or mania may be produced where the epileptic neurosis exists. They are really cases of acute general ma- nia, only they are of much shorter duration than acute general mania commonly is. There can be no difference of opinion as to the irresponsibility of a person who commits a crime when labouring under such an attack, if there be satisfactory evidence of its occurrence. A difficulty might occur when the paroxysm was very short, and when there were no witnesses to testify to its nature: coming on sud- denly and passing off suddenly, it is possible that it might be overlooked. This is more likely to hap- pen when the crime falls short of murder, as there is not then an equally merciful inclination to find an excuse, nor is an equally minute inquiry made into the person's antecedents. While conceding unhesitatingly the occurrence of an acute attack of transitory mania on the occa- sion of a sufficient exciting cause, where there was an epileptic neurosis or an insane neurosis, or where there had been an injury to the head which had af- 268 RESPONSIBILITY IN MENTAL DISEASE. fected the mind at the time or afterwards, or where a previous attack of insanity had left behind it a tendency to the recurrence of the disease, I certain- ly hold that we ought to regard with extreme sus- picion the allegation of transitory mania in excuse of crime where none of these conditions were pres- ent. Possibly there may have been a sudden out- break of insanity which ceased as suddenly as it came on ; but, unless there was strong evidence of it other than the crime, it would be proper to refuse to admit it. Before concluding this chapter it will be con- venient to say something with regard to a condition of consciousness that has some resemblance to those peculiar states of consciousness which are sometimes evinced in epilepsy; I mean the state of somnambu- lism. There can be no doubt that some persons may rise from their beds while asleep, go through a series of complicated actions, and retire to bed again without awaking; in the morning feeling weary, tired, and out of sorts, but remembering nothing of what they have done, or remembering it only as a dream. If a crime were done by a person in this condition, there could be no question of responsibil- ity. But it must be borne in mind that somnambu- lism might easily be pretended, and assuredly the assertion of its occurrence for the first time when a crime had been done would be extremely suspicious. It is really, if not itself a kind of nervous disorder, very closely allied to such nervous disorders as epi- lepsy, catalepsy, and hysteria ; it certainly indicates EPILEPTIC INSANITY. 269 a decided neurosis; wherefore if any one really was subject to it, there could hardly fail to be evidence of its previous occurrence or of distinct nervous troubles.* Most physicians have in the course of their experience met with genuine instances of som- nambulism ; but few, I imagine, can call to mind an instance in which an act of homicide or incendia- rism has been perpetrated during sleep. The re- corded cases have been quoted over and over again by successive authors, but they do not thereby gain any more weight than attaches to the original au- thority, and it is no easy matter to get at this and to test its value. Having regard, however, to the com- plicated acts which somnambulists unquestionably do perform in their sleep, there is certainly no reason in the nature of things why they should not set fire to the house, or commit suicide or homicide.! There is a condition intermediate between sleep- ing and waking in which, before consciousness is * I was not aware, when this was written, that the old med- ical writers had pointed out the affinity between epilepsy and somnambulism. But I learn from a recently published work on Megrim and Sick Head-ache, by Dr. Liveing, that Dr. Darwin, the distinguished author of Zoonomia, noticed it, and that Dr. Prichard also called attention to it. f The American newspapers have recently contained the ac- count of a boy who in his sleep killed another boy, having left his bed in a state of somnambulism, and mounted into his vic- tim's room by means of a ladder. When in prison, he got up in the night in a state of somnambulism, laid hold of a razor, and attempted the life of another prisoner. 270 RESPONSIBILITY IN MENTAL DISEASE. fully restored, the ideas and hallucinations of a dream persist for a time; so that a man, even though awake, shall think he sees the images or hears the voices of his dream. " On awaking one morning out of a distressing dream," says Spinoza in one of his letters, " just as day was breaking, the images I had had present to me in my dream floated before my eyes as distinctly as if they had been actual objects. One form in particular, that of a leprous negro, whom I had never seen in my life, presented itself to me with singular distinctness, but faded and in a great measure disappeared when, to turn my thoughts to something else, I fixed my eyes on a book; as soon, however, as I allowed my eyes to wander from the page, the vision of the blackamoor presented itself with the same vividness as before. By-and-by it began to fade, and anon it disappeared entirely." To the same effect hear Casau- bon :—" Aristotle, in his treatise on Dreams, gives an instance of it in children and young boys; who after some terrible dream, though they be out of their dream, and their eyes full open (and light brought in sometimes, which I add because I know it to be true), think nevertheless for a while after that they see with their eyes what they saw in their dream. And Yitus Amerbachius, a learned man, in his book De Anima, lib. 4, confirms it to be true by his own experience, even when he was a man, if I mistake him not. But, whatever be the cause, the effect is certain." Most persons who have attended to their mental states will be able to EPILEPTIC INSANITY. 271 furnish similar instances from their own expe- rience. What it is important for us to bear in mind in regard to these persistent dream-images is that, in the mental confusion of the moment, they may lead to respondent actions. There are on record well- authenticated cases in which persons who have been aroused from a frightful dream, in which they im- agined that their lives were threatened, have vio- lently attacked those who have awakened them, having seen in them the enemies from whom they dreamed they were in danger. Marc reports the following remarkable case of Bernard Schedmaizig, who awoke suddenly at night, and saw, as he be- lieved, a frightful phantom. He twice called out, "Who is that?" and, receiving no answer, and imagining that the phantom was advancing upon him, he seized a hatchet which was beside him, attacked the spectre, and killed his wife. A some- what similar case has been recorded:—A constable heard in the middle of the night a distressing cry of " Save my children!" proceed from a house. Hastening into it he met a woman in her night- dress, who was in the greatest confusion and excite- ment. Everything in the room was in disorder, and two children cowered in one comer. Their mother cried repeatedly, " Where is my child ? Have you caught him ? I must have thrown it out of the win- dow." She had thrown it through one of the panes of the window, without opening it. She had dreamed that her children cried out to her that the house 272 RESPONSIBILITY IN MENTAL DISEASE. was on fire, and in the confusion of waking had thrown her youngest child out of the window in order to save it.* I doubt not that in this condition of brief tran- sitory delirium the mental state is very much like that which sometimes occurs in epileptics immedi- ately after a fit, when on reviving to consciousness they break out into delirium; only it is of much shorter duration. It may be a question in some of these cases whether an overlooked epileptic attack, either in the form of vertigo or of convulsions, has not actually preceded the mental confusion and ex- citement of the half-waking delirium. However it may be caused, it ought certainly to exempt from responsibility any one who is so unfortunate as to commit violence when thus deprived of the con- sciousness of the nature of what he is doing. * Bucknill and Tuke's Manual of Psychological Medicine. CHAPTEE VIII. SENILE DEMENTIA. Symptoms of senile dementia in the order of their occurrence: loss of memory, impairment of perception, incoherent talk, incapacity of comprehension, complete mental decay—Com- parison of its symptoms with those marking the natural de- cay of mind in old age—The mental character of old age- Failure of mind in febrile and other diseases—Loss of con- sciousness of personal identity—Aphasia. In this chapter I propose to describe briefly the phenomena which mark senile dementia, forasmuch as important questions of testamentary capacity not unfrequently arise when an old person whose facul- ties have undergone decay makes a will which is disappointing to those who have been looking for- ward to be' his heirs. These phenomena have the further interest of exhibiting in a striking way the progressive decay of mind which accompanies decay of brain; a decay which in some instances almost reaches mental extinction before bodily dissolution. At the outset the natural decline of the mental faculties which in greater or less degree commonly accompanies the bodily decline of old age, should be distinguished from that greater loss of mental power which is known as senile dementia; notwithstand- 273 274 RESPONSIBILITY IN MENTAL DISEASE. ing that between the least degree of the former and the worst stages of the latter there are all degrees of transition. It will be easily seen, then, that dif- ficult medico-legal mquiries must sometimes occur in such cases, and that the decision, whatever it be, may challenge criticism. The first marked symptom of the mental decay of senile dementia is an impairment of memory, especially of recent events. The past may be re- called with exactness; but recent impressions make no mark, soon pass away, and are forgotten. It is not that they are not rightly apprehended at the time, for at this early stage perception takes place properly, but they are not retained. So it happens that the visit of a friend, or some similar event, which caused interest at the time, is clean forgotten after a few days, while a similar event of former years is remembered accurately. Because of the way in which impressions occasioned by present cir- cumstances slip from the mind, while the ideas of the past abide, there is a want of connection be- tween the circumstances of daily life and the habit- ual thoughts, and the person may talk and act in a way that is inconsistent with actual facts. Suppose him to have received notice of some property hav- ing been left to him, or the death of some one whom he intended to remember in his will, it is quite possible that he might forget it, while retain- ing unimpaired, or not greatly impaired, the power of reasoning within the sphere of his recollection, and while remaining, therefore, capable of making SENILE DEMENTIA. 275 a just and rational disposition of such property as he knew he possessed, and of doing right to those who were present to his mind. Or it may happen that, having made his will, he straightway forgets that he has done so, and begins after a short time to talk again of making his will. Hence there is often in such a case the appearance of a far greater men- tal aberration than the facts, when closely exam- ined, really betoken. Let the attention be actively aroused by some stimulus, and the facts brought clearly to his mind, he will apprehend them correct- ly and pass a sound judgment upon them, although a few hours or a few days afterwards he may not, if questioned, be able to give an account of what he has said or done : he may, in fact, be capable of making a will, though incapable, by reason of loss of memory, of taking proper care of himself and of managing his affairs. Following the failure of memory, or coincident with it in some cases, there is an impairment of the power of perception, so that the person fails ordina- rily to apprehend all the qualities of an object, and so makes mistakes as to the identities of persons or places. The activity of his mind being mainly in the past, his memory of the lapse of time lost, and his perception of present circumstances blunted, trains of ideas are mistaken for realities, and he talks as if he were now in a place where he was formerly, or supposes a person whom he sees for the first time to be some one whom he knew years ago. Nevertheless, when his attention is called to the mis- 276 RESPONSIBILITY IN MENTAL DISEASE. take, he recognises it and wonders perhaps how he could have made it, though he may make it again next day. He may sell his property and speak of it as his afterwards; ask the same question over and over again, forgetting that it has been asked and an- swered ; not recognise one whom he had previously known well; inquire after the health of some one who has been dead for some time, or ask after the health of the person with whom he is talking as if he were asking after it from some one else. And yet it may be proved by documents that he is all the while filling up and signing cheques correctly, keeping his accounts accurately, and making no mis- take in the management of his affairs. It is an important fact to be borne in mind that there may be great variations in his mental condi- tion at different times according to his state of bodily health or to other causes of which we cannot always give an account. It will happen that he one day remembers an event of which he evinces no re- membrance on another day, or that on one occasion he makes a mistake as to the identity of a person whom he recognises perfectly on another occasion. These variations in the degree of his memory and in the measure of his apprehension are indeed marked features of his condition. On one occasion I visited and examined an old lady, finding nothing more the matter with her mental state than loss of memory with regard to time ; but when I visited her again a short time afterwards in company with her nephew, I found, after he had left the room, SENILE DEMENTIA. 277 that she confounded him with his grandfather, re- garding whom she retained the memory of some offence, and abused him accordingly, although she had seemingly recognised him when he was present and spoken kindly to him. Matters becoming worse, as the effacing action of decay proceeds, the impairment of memory and the loss of power of perception increase. The indi- vidual fails to recognise those about him while con- stantly receiving their attentions, and forgets every- thing that occurs directly it has occurred. Even the past is not remembered coherently; incidents and persons are jumbled together in a confused way, and the conversation is a fragmentary and incoherent rambling. He does not recognise where he is, has no notion of the day of the week, or of the time of day, and will get up in the night insisting that it is daylight, or go to bed in the daytime ; will believe that he is engaged daily in occupations which he has not touched for years, or wonder why he is not so engaged, and blame those whom he imagines to be preventing him. Conversation he cannot follow, and only understands the simplest question when it is slowly and distinctly addressed to him; or, appre- hending its meaning and attempting to answer, he is incapable of carrying on the series of thoughts to the end of a sentence, his mind becomes confused and bewildered before he has uttered the half of his reply, and his expressions are consequently ab- surd and irrelevant. Feeling is involved with intel- ligence in the common " ruin of oblivion; " by the 19 278 RESPONSIBILITY IN MENTAL DISEASE. ravages of decay he is brought to the philosopher's ideal of freedom from passion, although it some- times happens that the remembered fragment of a former grudge gives a temporary animation to the language of his dotage. Finally, he cannot compre- hend a simple question, does not understand at all; and his reply, if he makes one, is utterly ir- relevant and incoherent. His habits are often un- cleanly ; he has lost even the animal instincts and propensities; and so he lingers superfluous on the stage until exhaustion or apoplexy carries him off. Before this last stage of decay is reached, however, there are sometimes delusions with periods of ex- citement : he has fears that some injury is to be done to him—that he is to be robbed, ruined, or killed, does not sleep, complains and cries out, and is at times maniacal. Paroxysms of noisy excite- ment, with delusions and apprehensions of the char- acter described, are, indeed, not uncommon features of senile dementia at one stage or other of its course. Such is the course of senile dementia—a grad- ually increasing decay of mind until there is nothing left that we properly called mind. Let me consider briefly the manner of its beginning, and compare its symptoms with the earliest indications of that nat- ural decay of mental power which accompanies old age. For there is a character of mind which be- longs to old age. The old man is sagacious, prudent, circumspect, sober in conjecture, ripe in judgment, measured in his language as in his movements; he SENILE DEMENTIA. 279 performs his ideas and his movements slowly and cautiously, for he has lost much of the energy and suppleness of his mind and frame ; his imagination is less brilliant and fruitful, and there is a languor of his intellectual faculties, although, under the in- fluence of an active stimulus, they may momentarily reach their former height of energy. He ceases to take interest in and to duly appreciate the present; cannot assimilate new things, but withdraws himself from participation in new movements, with which he feels no sympathy, to which he feels rather anti- pathy ; is without initiative, shrinks from enterprise, accepts only the lessons of the past, is the laudator temporis acti, and brands often as revolution what he ought to welcome as evolution. The diminution of the power of assimilation by the brain, which is the first result of its commencing decay, renders him incapable of truly receiving or apprehending the lessons of the present, and so deprives him of what is essential to a just comprehension and judg- ment of it; so that, although an old man may be helpful in council out of the stores of his experience, he is by no means to be trusted as a leader in ac- tion. Let me note, then, that his loss of power of reception or apprehension of the quality and bear- ing of events is the beginning of that decay which ends by natural descent in the loss of perception which is so marked a character of senile dementia. Again there is in the old man not only an unwilling- ness or inability to receive, but an incapacity to hold or retain new impressions; the brain has lost both 280 RESPONSIBILITY IN MENTAL DISEASE. susceptibility to impressions and its power of regis- tering them, wherefore they pass away without per- manent effect upon the mind ; a condition of things marking the beginning of that decay which passes by a natural descent into the striking loss of mem- ory of recent events in senile dementia. Further- more, the mind of the old man fails in the power of reproduction or recollection, so that ideas cannot be recalled through the established tracks of associa- tion. Lastly, from these three causes combined— failure of apprehension, of memory, and of recollec- tion, there is necessarily a failure of the power to combine old and new into a new product of mental activity—a failure, that is, of productive imagina- tion. This is the commencement of that decay which finally declares itself in the loss of power of comparison of ideas and in the incoherence of senile dementia. To these stages of failure of intellect we may add the decline of the moral faculties which commonly accompanies old age, a decline which, in dementia, may reach the stage of complete extinc- tion of them. It appears then from what has been said that the characters of senile dementia mark a further stage of the same kind of degeneration which is exhibited in the earliest symptoms of the mental decay of old age. It must not be supposed, however, that the transition from the latter to the former state takes place in every case, or that when it does take place, it is always a quiet and gradual decline. In some cases the occurrence of actual dementia is ushered SENILE DEMENTIA. 281 in by a condition of excitement which gives a facti- tious energy to the individual, deceiving perhaps himself and his friends; he may suddenly exhibit an extraordinary activity in business or in specula- tion, making sales or investments of a startling kind, or he may break out into sexual, alcoholic, or other excesses; impatient of advice or opposition, he re- sents all interference or control, and sometimes occa- sions, by his conduct, no little distress and perplexity to his family. The excitement is really a sort of outburst of expiring energy, and is followed by de- mentia, the transition from the one to the other being sometimes quite sudden. It is interesting to note that very similar mental symptoms to those which are produced by the brain- decay of old age may be produced by other causes which inflict damage, temporary or permanent, upon the brain. We observe the same gradations of fail- ing memory in febrile diseases, after injuries to the head, after apoplexy sometimes, and in persons broken down by intemperance. Yery notable in the earlier stages of febrile diseases, and in debility after acute diseases, is the first stage of failing memory in which attention cannot be directed to a long train of thought, or to anything requiring a continued effort of mind. At a later stage of fever, it is evident that impressions do not leave any remembrance, though at the time there appears to be a perfect perception ; there is apprehension followed by com- plete forgetfulness. At a still later period external impressions are not perceived at all, or are perceived 282 RESPONSIBILITY IN MENTAL DISEASE. in a manner which cannot convey any distinct no- tion of their relations, while trains of ideas are believed to be realities. With this incapacity of present apprehension there may be observed, as in senile dementia, a wonderful activity of past ideas and the revival of memories which had been lost, so that a person in delirium will sometimes rave in a language of which he can scarcely remember a word when in health. Lastly, a state of stupor supervenes in which the mind is entirely cut off from the ex- ternal world, and in which there is no internal activ- ity, or not more than the occasional flicker of an expiring idea. In the act of dying, when death is not sudden, the same stages of failing memory and failing mind are often passed through; and whoso- ever would realise what his probable mental state will be in that last scene of all, when he has the stage all to himself, and easily excites interest, how- ever poorly he plays his part, may help himself to do so by a study of these successive stages of mental decay. It is no wonder that the thoughts of child- hood then come back to the mind, and that the dying man sometimes babbles in words which he had never used in his riper years; and those who would make much of these expressions when they are of a religious character, would do well to reflect that they are attending upon a pathological scene, and to take heed lest they found conclusions agree- able to themselves upon the phenomena of mental decay. In these conditions of mental decay a man may SENILE DEMENTIA. 283 lose the consciousness of personal identity, and it were much to be wished that metaphysicians who lay such great stress on the unity of the ego, and make so much use of it in their systems of philoso- phy, would explain, from their point of view, the phenomena of disordered identity. Surely a mind, even though manifesting itself through broken glimpses in a damaged brain, should not lose its consciousness of personal identity—should not be ignorant whose mind it is. To the physiologist, who sees in the unity of the ego simply the full and harmonious action of the different parts of the mental organisation, it can cause no surprise that, when the defacing action of decay has destroyed centres of thought and paths of association, there should be a break of the harmony of function and a disruption of the unity of consciousness. The won- der would be if it were otherwise. It would seem quite natural that as mental function flickers irregu= larly and finally ceases before organic actions cease, there should be a loss of consciousness of identity before, through the death of the body, individuality is altogether extinguished, and that which was an individual blends with external nature. I have described specially the phenomena of senile dementia, but there are other conditions of mental impairment produced by disease which it would be too long a task to describe here: apo- plexy, for example, may occasion all sorts and de- grees of loss of memory, with weakness of mind, the study of which is well fitted to throw light 284 RESPONSIBILITY IN MENTAL DISEASE. upon the obscure relations of body and mind. There is, however, one peculiar state produced sometimes by an apoplectic attack of which I may say a few words—namely, an entire loss of the fac- ulty of speech. In this condition, which is known as Aphasia, there is no loss of power over the mus- cles of speech, no paralysis of them; but there is a complete forgetfulness of the words which are the expressions of the thoughts ; the person appears to understand in some cases all that is said to him, but # he cannot answer a wrord; like Zacharias when he had seen the vision in the temple, he is speechless; when he attempts to speak, he either makes a vain movement of his mouth, or utters an unmeaning sound. In other cases the person does not forget words altogether, but substitutes wrong words for those which he wishes to use; wanting bread, for example, he asks for his boots, and is annoyed and angry when his boots are brought to him. When the right word is suggested to him, he may correct himself, or may show by the expression of his face that he perfectly understands it. This condition is usually associated with paralysis of the right side of the body, and has been supposed to be produced by disease or injury of a convolution of the left side of the brain—the third left frontal convolution, which has accordingly been declared by some to be the seat of the faculty of articulate language. It is obvious that difficult questions must some- times arise with regard to the amount of under- standing which a person who is in this aphasic state SENILE DEMENTIA. 285 actually possesses: having lost the usual means by which intelligence is manifested, there will neces- sarily be a difficulty in gauging the measure of it. Hence it has happened that wills made by persons suffering from aphasia have been disputed. Some observers, chief among whom was the distinguished French physician Trousseau, have maintained that the understanding is always more or less defective in aphasia, and that those persons who, having suf- fered from it and having recovered, have declared that all the time of their affliction they were in per- fect possession of their understanding, were really mistaken about themselves. They were something like persons in dreams who fancy themselves to be reasoning profoundly and discoursing most elo- quently, although all the while their ideas are inco- herent, and what they say is unintelligible. It is an obvious remark that, if a man's understanding be perfect, he ought to be able to show it even though he has lost the power of articulate speech, speech being but one variety of the language of ex- pression. He cannot write because his right hand is paralysed; but if that were all he might soon learn the not very difficult task of writing with his left hand, or might put together separate letters so as to frame the words which he wanted. In some instances he can do so. In the St. George's Hos- pital Keports for 1867, Dr. William Ogle relates the case of a person who could write with his left hand words wdiich he could not pronounce when asked, however hard he tried. His mind seemed 286 RESPONSIBILITY IN MENTAL DISEASE. quite clear, for he took an interest in what was going on around him, understood all that was said, listened, laughed, and expressed himself by suitable pantomime. In many other instances it unfortu- nately happens that there is a loss of the power of expression by writing as well as the power of verbal expression—a condition of what is called agraphia as well as a condition of aphasia: the person may understand words written as well as words spoken, but he cannot express himself either in the one way or in the other. This is not the place to discuss the general ques- tion of the nature of aphasia, which is as interesting in a psychological point of view as it is difficult; all that we are concerned with is the practical question whether an aphasic person is competent to make a will. It is quite possible that he might not be capa- ble of sustained thought, might have suffered some impairment of thought, feeling, and will, and yet might know the nature and amount of his property, and be competent to express his wishes with regard to the disposal of it. Certainly we should not be warranted by the facts in affirming that an aphasic person is necessarily deprived of testamentary ca- pacity. In one case which was tried in the English Probate Court—Peacock v. Jjowe—but which was compromised at the conclusion of the evidence in favour of the will, very strong testimony as to the testator's general intelligence was given by those who were acquainted with him. He could not ex- press himself by speech; but he kept by him a die- SENILE DEMENTIA. 287 tionary to which he used to refer, and in which he indicated the required word, and on the whole suc- ceeded thus in conveying his meaning in an intelli- gible manner. On the other hand, there are un- doubtedly cases of aphasia in which the intelligence is very greatly impaired, and the sufferer quite in- competent to make a will. Each case must be de- cided on its own merits according to the evidence of the mental condition of the person as exhibited in his general conduct and in his particular manner of making known his wishes. 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 in- sanity—The gradual evolution of character—The develop- ment 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 de- generation and regeneration of families—The intensifica- tion of the neurotic type—Hereditary predisposition, intem- perance, and mental anxieties as causes of insanity— Exposition of the evil effects of intemperance—The pre- vention of insanity by education—The aim of a liberal education—Self-culture as an aim in 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 require- ments 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 men- tal 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. Most persons who have suffered from the malady of thought must at one period or other of their lives have had a feeling that it would not be a hard matter 288 THE PREVENTION OF INSANITY. 289 to become insane, that in fact something of an effort was required to preserve their sanity. To those in whose blood a tendency to insanity runs this effort must without doubt be a sustained and severe one, being no less in some instances than a continual struggle to oppose the strong bent of their being. How far then is a man responsible for going mad ? This is a question which has not been much consid- ered ; yet it is one well worthy of deep - considera- tion ; for it is certain that a man has, or might have, some power over himself to prevent insanity* However it be brought about, it is the dethronement of will, the loss of the power of co-ordinating the ideas and feelings ; and in the wise development of the control of will over the thoughts and feelings there is a power in ourselves which makes strongly for sanity. From time to time we may see two persons who have had the same faulty heritage, and who, so far as we can judge, have not differed much in the degree of their predisposition to insanity, go very different ways in life—one perhaps to reputa- tion and success, the other to suicide or madness. A great purpose earnestly pursued through life, a purpose to the achievement of which the energies of * More than twenty years ago, a small volume, entitled "Man's Power over Himself to prevent or control Insanity," was published. It contained the substance of two lectures given at the Royal Institution, by the late Reverend John Bar- low, and was one of a series of Small Books on Great Subjects. Though excellent of its kind, the author regards the subject en- tirely from a moral point of view, and certainly in some respects overrates the power of control. 290 RESPONSIBILITY IN MENTAL DISEASE. the individual have been definitely bent, and which has, therefore, involved much renunciation and dis- cipline of self, has perhaps been a saving labour to the one, while the absence of such a life-aim, whether great in itself or great to the individual in the self-discipline which its pursuit entailed, may have left the other without a sufficiently powerful motive to self-government, and so have opened the door to the perturbed streams of thought and feel- ing which make for madness.. Curious and interesting in this relation is it to observe in what strange and saving outcomes of action a vein of madness in the constitution some- times displays itself; perhaps in an extreme miser- liness, perhaps in the fanatical adoption of extreme religious opinions and practices, not seldom nowa- days in the follies of an imagined intercourse with the spiritual world, sometimes in a morbid vein of poetical delirium, and sometimes in the eager advo- cacy of extreme social or political theories. These will serve as general illustrations of what I mean, but it will be understood that there are numbers of particular eccentricities having the same meaning which it is impossible to enumerate here. Sad, foolish, or dangerous as such extravagances may seem in some instances, they may be regarded with indulgence as the directions of development which insane tendencies happily take ; happily, I may justly say, because, but for them, the result might unhap- pily be actual insanity. They are a vicarious relief, a sort of masked madness. THE PREVENTION OP INSANITY. 291 When we come to consider the advice which it would be right to give for the guidance of one who was anxious to do that which might protect him from an attack of insanity, the greatness and the difficulty of the subject appears almost overwhelm- ing. There can be no doubt that in the capability of self-formation which each one has in greater or less degree there lies a power over himself to pre- vent insanity. Not many persons need go mad per- haps—at any rate from moral causes—if they only knew the resources of their nature, and knew how to develope them systematically. A practical ex- perience of the insane teaches us what a power of self-control even they sometimes evince when they have a sufficient motive to exert it. The fear of suffering by yielding to their insane propensities suffices in many instances to hold them in check; the occasional concealment or actual denial of their delusions, if they have something to fear from the discovery of them, or something to gain by the concealment of them, testifies to a power over them- selves which sane persons might sometimes envy. The descriptions of cases of suicidal and homicidal mania which I have given in foregoing chapters show how even desperate insane impulses have been successfully resisted for a time in some in- stances, and resisted altogether in other instances. It is, indeed, in consequence of the power of self- control which insane persons have, and of the way in which those who have the care of them elicit it, that asylums have become for the most part quiet 292 RESPONSIBILITY IN MENTAL DISEASE. and orderly institutions, instead of being places of disorder, fury, and violence. The beginning of re- covery from mental derangement is always a revival of the power of will; such revival being possible forasmuch as the disease in many of its forms is unattended with organic morbid changes—is func- tional not organic. If the power then exists in the insane mind in such degree as to prevent the manifestations of madness, and, when aroused to action, to inaugurate recovery from it, is it not rea- sonable to suppose that it might, had it been prop- erly trained and exercised originally, have sufficed to prevent its occurrence ? The pity of it is that the power is often least developed where it is most wanted. It would be quite useless to inculcate rules for self-formation upon one whose character had taken a certain mould of development; for character is a slow and gradual growth through action in relation to the circumstances of life ; it cannot be fashioned suddenly and through reflection only. A man can no more will than he can speak without having learned to do so, nor can he be taught volition any more than he can be taught speech except by prac- tice. It was a pregnant saying, that the history of a man is his character; to which one might add that whosoever would transform a character must undo a life history. The fixed and unchanging laws by which events come to pass hold sway in the domain of mind as in every other domain of nature. THE PREVENTION OF INSANITY. 293 A striking illustration of the difficulty of realis- ing the reign of law in the development of char- acter and in the events of human life is afforded by the criticisms of those who have blamed Goethe because he made Werter commit suicide, instead of making him attain to clearer insight, calmer feeling, and a tranquil life after his sorrows; had they re- flected well they must have perceived that suicide was the natural and inevitable termination of the morbid sorrows of such a nature. It was the final explosion of a train of antecedent preparations, an event which was as certain to come as the death of the flower with a canker at its heart. Suicide or madness is the natural end of a morbidly sensitive nature, with a feeble will, unable to contend with the hard experiences of life. You might as well, in truth, preach moderation to the hurricane as talk philosophy to one whose antecedent life has con- ducted him to the edge of madness. I cannot but think that moral philosophers have sometimes exaggerated greatly the direct power of the will, as an abstract entity, over the thoughts and feelings, without at the same time having taken sufficient account of the slow and gradual way in which the concrete will itself must be formed. The culminating effort of mental development, the final blossom of human evolution, it betokens a physio- logical development as real, though not as apparent, as that which distinguishes the nervous system of man from that of one of the lower animals. Time and systematic exercise are necessary to the gradual 20 294 RESPONSIBILITY IN MENTAL DISEASE. organisation of the structure which shall manifest it in full function. No one can resolve successfully by a mere effort of will to think in a certain way, or to feel in a certain way, or even, which is easier, to act always in accordance with certain rules; but he can, by acting upon the circumstances which will in turn act upon him, imperceptibly modify his character: he can thus, by calling external circum- stances to his aid, learn to withdraw his mind from one train of thought and feeling, the activity of which will thereupon subside, and can direct it to another train of thought and feeling, which will thereupon become active, and so by constant watch- fulness over himself and by habitual exercise of will in the required direction, bring about insensibly the formation of such a habit of thought, feeling and action as he may wish to attain unto. He can make his character grow by degrees to the ideal which he sets before himself. The development of the power of co-ordinating in complex action various distinct muscles for the accomplishment of a special end is truly the devel- opment of the volitional power of such purposive movements; in like manner the development of the power of co-ordinating ideas and feelings for the achievement of a special life-aim is the development of the volitional power to achieve it. There is a mul- titude of concrete volitions, but there is no abstract will apart from the particular volitions. Just in fact as an individual gains by practice a particular power over the muscles of his body, associating them THE PREVENTION OF INSANITY. 295 in action for the performance of complicated acts, which, wdthout previous training, he could no more perform than he could fly, and rendering his muscles in this regard habitually obedient to the dictates of his will; so can he gain by practice a particular power over the thoughts and feelings of his mind, associating them in action for the accomplishment of a definite purpose in life, and rendering them in this regard habitually obedient to the dictates of the will in the pursuit of its ideal. Striking examples of the gradual development of the power of will over both movements and ideas under most unfa- vourable conditions are witnessed in our idiot asy- lums; the records of these establishments showing that there is hardly an idiot so low that he cannot be so far improved by patient and laborious culture as to acquire some power of self-government both in regard to his body and his mind. Great then as the power of will unquestionably is, when rightly developed, we ought not to lose sight of the fact that its development is effected only by the gradual education of a continued exercise in relation to the circumstances of life. It will be understood then how it is that when we consider deeply what advice should be given to a person who fears that he may become insane, we too often discover that we have none to give which will be of much real use to him. His character, de- veloped as it has been, will not assimilate advice that is counter to its affinities. We cannot efface the work of years of growth, cannot undo his men- 296 RESPONSIBILITY IN MENTAL DISEASE. tal organisation, and it is borne in upon us that ad- vice, if it was to do any good, should have guided the direction of education. The physician soon learns how little effect the best counsels have upon those who, having a tendency to insanity, come to him to ask what they shall do to be saved from the threatened danger: they listen attentively, assent perhaps gratefully, go their ways, and do—exactly as they did before. But if we were seriously minded to check the increase or lessen the production of insanity, it would be necessary to begin even farther back, and to lay down rules to prevent the propagation of a disease which is one of the most hereditary of dis- eases. Although it cannot, like small-pox or fever, be communicated from individual to individual, and so be spread through a community, the lunatic being happily in a minority of one in the world, and not commonly infecting other persons with his morbid belief, yet unhappily it is a disease which, having ex- isted in the parent, may entail upon the child a pre- disposition more or less strong to a like disease. If there is one conviction which a widening experience brings home to the practical physician, it is a con- viction of the large part which hereditary predispo- sition in some form or other plays in the causation of insanity: it would scarcely be an exaggeration to say that few persons go mad, save from palpable physical causes, who do not show more or less plainly by their gait, manner, gestures, habits of thought, feeling and action, that they have a sort of predes- THE PREVENTION OF INSANITY. 297 tination to madness. The inherited liability may be strong or weak; it may be so weak as hardly to peril sanity amidst the most adverse circumstances of life, or so strong as to issue in an outbreak of madness amidst the most favourable external cir- cumstances. Now it is certain that if wre were in- terested in the breeding of a variety of animals, we should not think of breeding from a stock which was wanting in those qualities that were the highest characteristics of the species: we should not will- ingly select for breeding purposes a hound that was deficient in scent, or a greyhound that was deficient in speed, or a racehorse that could neither stay well nor gallop fast. Is it right then to sanction propa- gation of his kind by an individual who is wanting in that which is the highest attribute of man—a sound and stable mental constitution ? I note this as a question to be seriously faced and sincerely an- swered, although not expecting that mankind, in the present state of their development, will either seriously face it or sincerely answer it. When one considers the reckless way in which persons, whatever the defects of their mental and bodily constitution, often get married, without sense of responsibility for the miseries which they entail upon those who will be the heirs of their infirmities, without regard, in fact, to anything but their own present gratification, one is driven to think either that man is not the pre-eminently reasoning and moral animal which he claims to be, or that there is in him an instinct which is deeper than knowledge. 298 RESPONSIBILITY IN MENTAL DISEASE. He has persuaded himself, rightly or wrongly, that in his case there is in the feeling of love between the sexes something of so sacred and mysterious a character as to justify disregard to consequences in marriage. We have only to look at the large part which love fills in novels, poetry and painting, and to consider what a justification of unreason in life it is held to be, to realise what a hold it has on him in his present state of development, and what a repugnance there would be to quench its glow by cold words of reason. At bottom, however, there is nothing particularly holy about it; on the con- trary, it is a passion which man shares with other animals; and when its essential nature and function are regarded, we shall nowhere find stronger evi- dence of a community of nature between man and animals. It is in this community of nature that we may perceive the explanation of the excitement, rejoic- ings, personal decoration, and feastings which con- tinue to be the usual accompaniments of marriage, notwithstanding that reason might dictate a more quiet and sober carriage. For it would not be a very absurd thing if an ingenious person, consider- ing curiously what a solemn undertaking marriage is, and what serious responsibilities it entails, were to maintain that men and women should enter into it soberly and rather sadly, under a grave sense of responsibility, as upon an uncertain voyage, and should reserve their rejoicings for the journey's end, when, having acted well their parts, they THE PREVENTION OF INSANITY. 299 might fairly claim a nunc plaudite. But this would be contrary to the wray of nature, in which a similar exaltation is displayed when the time of marriage arrives. There is then a transport throughout the vegetable and animal kingdoms, which put forth all the beauty of their colours and all the harmony of their sounds; for the flowers are the dress of love, and the spring mel- odies of birds are love songs. The temperature of the plant is then increased, and it is arrayed in a floral glory such that " Solomon in all his glory was not arrayed like one of these ; " the birds put on a gayer plumage, and their exaltation bursts forth in raptures of varied melody ; everywhere the func- tions reach a transport or ecstasy of love. Man displays his harmony with nature by a similar ex- altation. In face of this instinct it would be a hard and unwelcome thing to lay down rules for the preven- tion and regulation of marriages in accordance with what might seem to be the sober dictates of reason, even if, which is not the case, science had arrived at such a degree of development as to be able to do so with exactness and authority. Moreover, we are not sure how great may be the compensating ad- vantages of seemingly unwise marriages. It will be easier and more agreeable to admit that for the present men must go on marrying and giving in marriage without much reflection, and to " trust the universal plan will all protect." Nevertheless ther,e is a certain amount of definite 300 RESPONSIBILITY IN MENTAL DISEASE. knowledge which we are bound to recognise, how- ever we may deal with it. It is a fact that a patho- logical evolution—or, more correctly, a pathological degeneration—of mind does take place through generations. The course of events may be repre- sented as something in this wise : in the first gen- eration we perhaps observe only a predominance of the nervous temperament, irritability, a tendency to cerebral congestion, with passionate and violent out- breaks ; in the second generation there is an aggra- vation of the morbid tendencies, displaying itself in cerebral haemorrhages, idiopathic affections of the brain, and in the appearance of such neuroses as epilepsy, hysteria and hypochondria; in the third generation, if no check has been opposed to the downward course, we meet with instinctive tend- encies of a bad nature, exhibiting themselves in eccentric, disorderly and dangerous acts, and with attacks of some forms of mental derangement; and finally, in the fourth generation, matters going from bad to worse, we meet with deaf-mutism, imbecility and idiocy, and sterility, the terminus of the patho- logical decline being reached. Such is the course of degeneration when it proceeds unchecked. But an opposite course of regeneration of the family by happy marriages, wise education, and a prudent conduct of life is possible; the downward tendency may be thus checked, and even perhaps effaced in time. As things are at present, such re- generation is always accidental, is never designed and deliberately aimed at. IJow it may be done THE PREVENTION OF INSANITY. 301 designedly and systematically is certainly a most complex and difficult enquiry, but it is one which lies within the range of human faculty. The first condition of the enquiry is that men should realise that such apparently capricious events as the imbe- cility of one child and the genius of another child are effects of natural laws, that they are not less so than are the complex chemical combinations and decompositions which at one time were as obscure, and seemed as irregular, uncertain and meaningless, but which are now known to take place with un- failing uniformity under the same conditions. Let the same amount of patient observation and labo- rious investigation which has been applied by a succession of distinguished men to unravel the mysteries of chemical combinations, be applied to the observation and investigation of the more com- plex mysteries of the degeneration and regeneration of families, and there can be no doubt that fight will be thrown upon the phenomena. Meanwhile men ought not to repudiate caution because observation is defective, and wilfully to in- cur needless risks : they will go on falling in love, and, having fallen in love, they will go on marry- ing, and having married they will go on producing children, but there is no reason why a person hav- ing a hereditary predisposition to insanity should fall in love with and marry a person who has a similar predisposition. Falling in love being much a matter of propinquity, they can keep out of the way of dangerous attraction, or if they have fallen 302 RESPONSIBILITY IN MENTAL DISEASE. in love they may surely pause before, in order to avoid the temporary suffering of an act of sharp self-renunciation, they resolve to run the almost certain risk of bringing untold miseries upon one or more of the offspring of an ill-advised union.* It is an unfortunate circumstance that the tend- ency often is to an intensification of the neurotic type. In the first place, those who have it are prone, by a sort of elective affinity, to seek in mar- riage persons who have similar mental qualities, and with whom, therefore, they have a sympathy of tastes, feelings, and thoughts. Emotional suscepti- bilities, wild flights of imagination, and empty idealistic aspirations, such as they themselves in- dulge, excite their admiration and sympathy; while common sense, subordination of feeling, sober re- flection, and a calm and regulated activity are re- pugnant to their nature. In the second place, by a similar natural affinity, they select those external circumstances of life the influence of which is adapted to foster rather than to check the special tendencies of their natures. They have not that strength of character and breadth of thought which would enable them to endure and learn to control * Insanity is so prevalent in some families that we have known two, three or four children of the same parents suffering under the disorder. In the family of a brother and two sisters there were ten cases of insanity—five in one family, two in an- other, and three in a third—out of twenty members."—Partial Derangement of the Mind, by John Cheyne, M. D. THE PREVENTION OF INSANITY. 303 whatever circumstances they might be placed in, and so to get the benefit of them, however repug- nant they might be, in self-culture; but eagerly seek such as are grateful to them, and so intensify their peculiar tendencies, until these perhaps under- go a pathological development. In the third place, they apply to their children the same mismanage- ment which they apply to themselves. These are twice cursed : they are cursed in the inheritance of a bad descent, and in the training which they get, or rather the want of training from which they suffer, in consequence of parental peculiarities and defects. Here, then, are three important causes of an aggra- vation of a neurotic type which it does not lie be- yond the wisdom and power of mankind greatly to obviate.* * It is impossible to place any reliance upon the information afforded by statistics concerning the influence of hereditary predisposition in the causation of insanity; the difficulty of getting at the truth on this matter being such as to render them quite untrustworthy. To base a conclusion on available statis- tics would be to vastly underrate its influence as a cause; whereas it is hardly possible, I believe, to overrate its actual im- portance. I am unwilling, for obvious reasons, to bring for- ward illustrations from my own experience; but in order to convey an idea of the character and extent of its probable operation, 1 may quote from a recently published paper the three following cases, which illustrate also the natural termina- tion of degeneration going on through generations:— A man, A. B., of congenital weak mind, had six children, three of whom died during childhood; the other three, one male and two females, were imbecile and were sent to an asylum at the respective ages of forty, forty-two, and forty-four. The male had previously married, but had no children. The females 304 RESPONSIBILITY IN MENTAL DISEASE. If we refer to the enumerated causes of insanity in any book which treats of the subject, or in the first asylum report which comes to hand, we shall find that hereditary predisposition, intemperance, and mental anxieties and troubles of some kind or other cover nearly the whole field of causation. These are causes which it should be the work of mankind to remove, or, if not to remove entirely, at any rate to abate considerably: hereditary pre- disposition, by abstention from marriage or by pru- dent intermarriage; intemperance, by temperance in living; mental anxieties, by the wise cultivation of the mind and by the formation of habits of self- government. Avoiding intemperance and other ex- cesses, we shall cut off not only the insanity which having had no issue, the family happily becomes extinct with the present generation. A man, C. D., labouring under dementia, whose first wife died insane, had by her a large family, four of whom, two sons and two daughters, inherited mental unsoundness. The two daughters have not had children. One of the sons is unmar- ried; the other is married and has had four children, all of whom died in childhood. But C. D. has had by a second wife, who is also insane, six children. Of these five died young, and the survivor is mentally defective. A man, E. F., while insane, committed suicide. His mother was insane, and her sister died in an asylum. His grandmother was insane, and his grandfather was a drunkard. His father is described as " eccentric;" his uncle was extremely morbid, and had a drunken son, who committed suicide. The other members of this family are, so far as can be ascertained, unmar- ried and without offspring.—" The means of checking the growth of Insanity in the Population." By Gr. J. Hearden, M. D. British Medical Journal, July 19, 1873. THE PREVENTION OF INSANITY. 305 is directly produced by it, but we shall prevent its indirect effects by cutting off a fruitful cause of hereditary predisposition to physical and mental degeneracy in the next generation; and by cutting off such native infirmities of brain and mind, we shall prevent the emotional agitations and explo- sions which are the consequences of such infirmi- ties and which -act as the so-called moral causes of the disease. While we must admit hereditary influence to be the most powerful factor in the causation of insan- ity, there can be no doubt that intemperance stands next to it in the list of efficient causes: it acts not only as a frequent exciting cause where there is hereditary predisposition, but as an originating cause of cerebral and mental degeneracy, as a producer of the disease de novo. If all hereditary causes of in- sanity were cut off, and if the disease were thus stamped out for a time, it would assuredly soon be created anew by intemperance and other excesses. A striking example of the effects of intemperance in producing insanity has recently been furnished by the experience of the Glamorgan County Asy- lum. During the second half of the year 1871, the admissions of male patients were only 24, whereas they were 47 and 73 in the preceding and succeed- ing half years. During the first quarter of the year 1873, they were 10, whereas they were 21 and 18 in the preceding and succeeding quarters. There was no corresponding difference as regards female admissions. There was, however, a similar experi- 306 RESPONSIBILITY IN MENTAL DISEASE. ence at the County prison, the production of crime as well as of insanity having diminished in a strik- ing manner. Now the interest and instruction of these facts lie in this—that the exceptional periods corresponded exactly with the last two " strikes" in the coal and iron industries, in which Glamor- ganshire is extensively engaged. The decrease was undoubtedly due mainly to the fact that the labour- ers had no money to spend in drinking and in de- bauchery, that they were sober and temperate by compulsion, the direct result of which was that there was a marked decrease in the production of insanity and of crime.* If men took careful thought of the best use which they could make of their bodies, they would probably never take alcohol except as they would take a dose of medicine, in order to serve some spe- cial purpose. It is idle to say that there is any real necessity for persons who are in good health to in- dulge in any kind of alcoholic liquor. At the best it is an indulgence which is unnecessary ; at the worst, it is a vice which occasions infinite misery, sin, crime, madness, and disease. Short of the pat- ent and undeniable ills which it is admitted on all hands to produce, it is at the bottom of manifold mischiefs that are never brought directly home to it. How much ill work would not be done, how much good work would be better done, but for its bane- * " Insanity and Intemperance." By D. Yellowlees, M. D. British Medical Journal, October 4th, 1893. THE PREVENTION OF INSANITY. 307 ful inspiration! Each act of crime, each suicide, each outbreak of madness, each disease, occasioned by it, means an infinite amount of suffering en- dured and inflicted before matters have reached that climax. It may of course be said that a moderate con- sumption of alcoholic liquors can do no harm, must on the contrary do good, when exhausted nature feels the need of some stimulant. I am not pre- pared to say that it does any demonstrable harm, but at the same time it is not wise to have recourse to an alcoholic stimulant when recourse ought to be had to food or rest; and it is a serious harm to the mind to gain, as is sometimes done, by the factitious aid of a stimulant, the energy which should come from the calm resolution of a developed will. What one sees happen often enough in life is this : there are persons of anxious and susceptible temperament who, having to meet some strain in their work, or some trial in their fives, are prone to take a stimu- lant in order to give themselves the necessary nerve; they fly to an artificial aid, which fails not in time to exact the penalty for the temporary help which it yields, instead of deliberately exerting their will and gaining thereby the advantage which such an exertion would give them on another occasion. Like the pawnbroker or the usurer, it is a present help at the cost of a frightful interest; and if the habit of recurring to it be formed, the end must be a bankruptcy of health. It is not possible to escape the penalties of weakening the will; sooner or later 308 RESPONSIBILITY IN MENTAL DISEASE. they are exacted in one way or another to the utter- most farthing : it is not possible, on the other hand, to overrate the advantages of strengthening the will by a wise exercise ; the fruits of such culture are an unfailing help in time of need. There are at least five distinct varieties of men- tal derangement which own alcoholic intemperance as their direct and efficient cause. Nor do other kinds of intemperance fail to play their part in the causation of mental disorders. Were men with one consent to give up alcohol and other excesses—were they to live temperately, soberly, and chastely, or what is fundamentally the same thing, holily, that is healthily—there can be no doubt that there would soon be a vast diminution in the amount of insanity in the world. It would be lessened in this genera- tion, but still more so in the next generation ; a part of which, as matters stand, will be begotten and bred under the pernicious auspices of parental excesses, and the infirmities and diseases engendered by them. But it is quite certain that men will not abandon their excesses in this day or generation ; that they will not adopt self-denying ordinances; that they will not be at the pains to cherish their bodies, so as to develop their powers to the best advantage, and to make them ready servants of an enlightened and well-developed will. They will go on as before, producing insanity from lack of self-denial; and when admonished of the steep and arduous path which they should follow, will go away, like one of old, sorrowful, because they have many passions. THE PREVENTION OF INSANITY. 309 It is to the perfecting of mankind by the thor- ough application of a true system of education that we must look for the development of the knowledge and the power of self-restraint which shall enable them, not only to protect themselves from much in- sanity in one generation, but to check the propaga- tion of it from generation to generation. It is not probable that much progress can be made in one generation ; for centuries are but seconds in the great process of human evolution ; none the less is it a duty to do all we can to carry it forward, in the confident hope that the day will down although it is yet only the twelfth hour of the night. Unhappily we are not yet agreed as to what should be the true aim and character of education. Regarding the subject from a scientific point of view, the best edu- cation would seem to be that which was directed to teach man to understand himself, and to understand the nature which surrounds him, and of which he is a part and a product ; so to enable him, as its con- scious minister and interpreter, to bring himself into harmony with nature in his thoughts and actions; and so to promote the progressing evolution of na- ture through him, its conscious self. The highest evolution of which man's being is capable, physical- ly, morally and intellectually, through knowledge of, and obedience to, those natural laws which gov- ern not only the physical world, but, not less surely, every thought and feeling which it enters into his mind to conceive—must be the aim of an education founded on a truly scientific psychology. But if 21 310 RESPONSIBILITY IN MENTAL DISEASE. this be the true aim of education, how vast a revo- lution remains to be accomplished! How many things are men yet taught which they ought not to be taught, and how many things are they not taught which they ought to be taught! To lay down the principles of mental hygiene on a scientific basis would, alas, be to offend many cherished beliefs, and to go counter to the convictions of all but a small minority of mankind. Nevertheless, I believe that the aims of a true education would, if sincerely recognised and earnestly pursued, do more than all the maxims of philosophy have done, and all the arts of medicine can do, to lessen the amount of in- sanity on earth. It will be admitted that as regards a knowledge of the laws of his own nature and of their relations to the laws of external nature, man is yet in a posi- tion of ignorance very like that in which the savages of old were, or the savages of to-day are, in regard to a knowledge of the laws of physical nature. Like them, he feels their effects without under- standing their nature; like them, he cherishes superstitious belief instead of systematically setting to work to enlighten his understanding ; like them, he puts up prayers where he should exert an intelli- gent will; like them, he suffers from the stern and inexorable dominion of laws which he has not been taught to understand, and which he does not even recognise when he suffers by them. No one can of course fail to testify, consciously or unconsciously, to the workings of natural laws in his being; he THE PREVENTION OF INSANITY. 311 witnesses to them, though he cannot trace them, in his thoughts, feelings, and actions, and thus inevi- tably acquires crude empirical rules to guide him; but the misfortune is that he is apt thereupon to assign an immediate supernatural agency, and to prostrate himself in helpless fear when he ought to proceed reverently to enquire and then intelligently to obey. Is there any fundamental difference be- tween the savage coming to destruction through ignorance of the law of gravitation and the civilised European coming to madness through ignorance of the laws of his own nature, and of the laws of the nature of things and men around him ? Insanity is simply a discord in the universe—the result and evidence of a want of harmony between an indi- vidual human nature and the nature surrounding it, and of which it is a part. The marvel is perhaps that there are not more insane persons than there are, considering how blindly men are yet compelled to live in very complex relations, how much they depend upon the crude instincts of empiricism, how little they have yet systematically done to know na- ture in themselves and themselves in nature. Let us not deceive ourselves with vain imagina- tions. The life of an individual in this age of civi- lisation is assuredly not a life in which the best use is made of his physical, moral, and intellectual ca- pacities. When we search into the causes of disease, how many diseases are directly or indirectly trace- able to breaches of those laws which govern the development and the health of the body! I have 312 RESPONSIBILITY IN MENTAL DISEASE. already laid stress upon the disastrous effects of in- temperance, and what I have said must suffice now as an illustration of disease caused by ignorance or disdain of the laws of health. But when we pass from the consideration of the management of the body to the consideration of that of mind, we shall discover as little evidence of a sincere desire and resolution to bring the feelings and thoughts into harmony with nature, and to develop the powers of the mind to the utmost. There is hardly any one who sets self-development before himself as an aim in life. The aims which chiefly predominate— riches, position, power, applause of men, are such as inevitably breed and foster many bad passions in the eager competition to attain them. Hence, in fact, come disappointed ambition, jealousy, grief from loss of fortune, all the torments of wounded self-love, and a thousand other mental sufferings— the commonly enumerated moral causes of insanity. They are griefs of a kind to which a rightly-devel- oped nature should not fall a prey. There need be no disappointed ambition, if a man were to set be- fore himself a true aim in life, and to work definitely for it; no envy nor jealousy, if he considered that it mattered not whether he did a great thing or some one else did it, nature's only concern being that it should be done; no grief from loss of fortune, if he estimated at its true value that which fortune can bring him and that which fortune can never bring him; no wounded self-love, if he had learned well the eternal lesson of life—self-renunciation. THE PREVENTION OF INSANITY. 313 But men exhibit a marvellous facility of deceiv- ing themselves; while professing to esteem those worldly aims as of little account, as infinitely trivial in comparison with the momentous concerns of the life to come, they at the same time concentrate all the real hopes, aspirations, and energies of their lives upon the pursuit of them. Thus their nature is an inconsistency; it is a house divided against itself, and how can it stand when trouble comes ? How can a nature be strong which is at war with itself, whose faith and works are in discord ? A decrease in the amount of insanity in the world would probably take place in a generation or two, if men were to cease to deceive themselves, and were to make their natures strong by making a real har- mony of them—if they would learn to be sincere to themselves in examining rigorously the foundations of their beliefs, and in estimating the quality of the aims which they actually pursue, and of the means by which they pursue them. There is a practice, highly esteemed in England, of carefully preserving certain animals called foxes, in order that they may be hunted to death for the amusement of men and women who follow the chase on horseback with extraordinary ardour and enthu- siasm. It is deemed an honour to be present at the death, when the exhausted beast is torn to pieces by the dogs, he or she who is the first to attain that en- viable position receiving as a trophy a share with the dogs in the fragments of its body—the tail. Artists are so full of admiration of the different 314 RESPONSIBILITY IN MENTAL DISEASE. scenes of the chase, that they employ their talents in painting them, and the pictures are purchased by lovers of the sport, in order to adorn the walls of their houses. Thus art lends its elevating influence to glorify the so-called manly sport, which, savage as it might seem, excites no horror in the most gentle breast. And yet, while this is so, there is in England an active society for the prevention of cruelty to animals, which takes no step to prevent this systematic preservation of animals for the sys- tematic infliction of suffering and death upon them as a sport, and which is even sincerely supported by foxhunters. Moreover, those who enthusiastically follow the cruel chase are followers also of the meek and lowly Nazarene. And they are unconscious of an inconsistency in themselves! If man's facility of self-deception were not incalculable, one knows not how he could dare face the judgment on his life, which he professes to expect after death, when the deliberate and systematic infliction of suffering has been his pleasure; not as an end, certainly, still as a means to an unworthy end. Boasting himself over the beasts that perish, he is probably the only ani- mal which inflicts suffering and death as a mere amusement for itself. I have not brought forward this illustration in order to speculate upon the possible influence of the pursuit of a cruel sport upon the character, but as one among other inconsistencies which might be ad- duced in order to point out the impossibility of real sincerity of thought while there is such flagrant self- THE PREVENTION OF INSANITY. 315 deception. This is indeed the evil of it. Uncon- scious self-deception it may be, but it is not less hurtful, nay, it is perhaps an indication of more hurt to character, on that account. No one can live in inconsistent habits of thought, feeling, and action, without injury to the sincerity and wholeness of his nature, and to the clearness and strength of his un- derstanding. While he fails to see in its true light such a cruel practice as the infliction of torture and of death for the purposes of his amusement, it is im- possible that he can see other things in their true fight. The best guarantee of clear apprehension, right feeling, vigorous understanding, and intelligent will, in any relation of life, lies in the formation of a habit of sound apprehension, right feeling, vigor- ous understanding, and intelligent will in former relations—in other words, in the sincere and thorough development of the intellectual and moral nature. The stronger and more complete this development is, the better will the individual be fortified against the inroads of any kind of mental degeneracy. There are many similar inconsistencies of thought and character which might, were this the place for it, be brought forward to show how far men yet are from doing justice to their mental faculties by developing them consistently to the utmost of their capacities. In order to do that successfully it will be necessary to set before themselves a worthy aim in life, and to work definitely for it. The question to be entertained and decided at the outset will be, whether this aim shall be internal or external— 316 RESPONSIBILITY IN MENTAL DISEASE. whether the individual shall seek first the completest development of which his nature is capable, other gains, such as riches, reputation, power, being al- lowed to fall to him by the way; or whether he shall seek worldly success, the formation of charac- ter being allowed to be a secondary and incidental matter ? It is a .vital question, the practical answer to which must influence most materially the training and cultivation of the mind. As a matter of fact it admits of no doubt that self-development is not made a life-aim; that such formation of character as takes place, does, in the great majority of men, take place, as it were, by chance, without premedi- tation, as an incidental effect of the discipline and training which they undergo in the pursuit of other life-aims. Is it any marvel, then, that the theoretical recognition of a higher aim in life which they make once a week as a conventional duty has no real in- forming influence in the formation of character; that it is a doctrine which, by an easy self-deception, is held on the condition of its being a sort of sleep- ing partner, and taking no active part in the man- agement of affairs? No argument is needed to prove that it must be hurtful to the intellectual and moral nature to hold a belief on such terms. Without doubt the practical aims of life, and the labour and self-denial necessary to the achieve- ment of them, do entail a large amount of self-dis- cipline of a more or less useful kind. But it is not less certain that the full development of the re- sources of the mental nature can be achieved only THE PREVENTION OF INSANITY. 317 by a deliberate culture and sustained activity of the mind as an aim in itself. A man may conduct suc- cessfully an important business or profession, once he has acquired the knowledge of it, without much real mental activity—almost automatically % indeed. By accustoming himself to attend habitually to a certain class of ideas, he is able to attend to them quite easily, to compare them almost unconsciously, and to carry out instinctively, as it were, the con- duct which they dictate; his knowledge and action become a sort of acquired instinct—the automatic work of nerve-centres that have been trained there- to, as nerve-centres are trained to perform easily the laboriously acquired function of walking. He observes, judges, and acts with as little conscious effort of attention as he uses for talking or walking, or as a skilful accountant uses in casting up a column of figures. It is true that the original labour of acquisition has cost him an expenditure of consider- able mental activity; but once the faculty has been acquired, it demands little attention, and if exer- cised within reasonable limits, occasions little fa- tigue. Plainly, then, an important business may be carried on without calling into action the higher faculties of the mind, by which the knowledge of it was in the first instance acquired; and it is no exaggeration to say that a great many persons never exercise any real mental activity, never undergo any real development, after they have become skilled in the special work of their fives. Their thoughts run 318 RESPONSIBILITY IN MENTAL DISEASE. in a groove so well worn that the difficulty is to get out of it. The higher faculties being unused undergo decay, if not degeneration; real mental application becomes first difficult and then impos- sible ; and when a calamity occurs they are without internal resources to enable them to bear up against its strain. When they are taken from the routine of their labours they have no interests, they can turn to no intellectual work, are a torment to them- selves and to others, as they go through the tedious process of a decay of mind. The matter is worse when a person has made success in business the one aim of his life, when he has by long concentration of desire and energy upon such an aim so com- pletely grown to it as to have made it the main part of his inner life—that to which all his thoughts, feelings, and actions are directed; then if some error of his own, or some misfortune beyond his con- trol, shatters his hopes, destroys the pride of his pre- vious accomplishments, lays low the fabric which he has been building with all the eagerness and energy of an intense egoism, he is left naked and defence- less against his afflictions, sinks into melancholy, and from melancholy into madness. To neglect the continued culture and exercise of the intellectual and moral faculties is to leave the mind at the mercy of external circumstances: with it as with the body, to cease to strive is to begin to die. If the foregoing remarks be true, it is obvious that when any one becomes insane who has been actively engaged in the conduct of a large business, THE PREVENTION OF INSANITY. 319 the fact cannot justly be accounted evidence of the powerlessness of mental activity to prevent insanity. His pursuit has failed completely to satisfy the re- quirements of a proper mental culture. It is the same with another great interest of life, which, were it as real as it is reputed to be, should exert a most powerful influence upon the development of the mental nature—namely, religion. The majority of men discharge its duties automatically, and accept its doctrines formally, paying to these a lip-homage, without ever having a distinct grasp of them, or ever pursuing them in thought to their logical con- sequences ; they believe vaguely, without ever caring to realise distinctly what it is that they think they believe; are content with a kind of belief which they would certainly at once repudiate in their worldly affairs. It needs no argument to prove that such a slovenly habit of thought is not only not conducive to, but is greatly hurtful to, mental culture, and that any mind which is content to hold beliefs on those terms is ill fortified by the develop- ment of its powers to exercise sound reflection on other subjects, or to react vigorously to the end under the burdens laid upon it. Furthermore, while the lessons of religion incul- cate the duty of subduing those passions which have their roots in a strong self-feeling, they do not, in the way they are too often taught, enforce that com- pleter self-renunciation which consists in the convic- tion of personal insignificance, and in the suppres- sion of egoism, even if it be the egoism of excessive 320 RESPONSIBILITY IN MENTAL DISEASE. sensibility and of a too tender conscience. There can be no doubt that harm is sometimes done to per- sons of a susceptible mind by encouraging or stimu- lating them to reflect upon their feelings, instead of inciting them to put the energy of their feelings into a well-ordered mental activity. There is but one true cure for suffering, and that is action; and a healthy mind, like a healthy body, should lose the consciousness of self in the energy of action. By self-introspection and self-analysis, especially when these are inculcated as a religious duty upon per- sons who, from bodily or other causes, are inclined to excessive susceptibilities, a morbid egoism is fos- tered, which is sometimes mistaken for an awak- ened conscience. But a tender conscience of that kind, overrating its own importance, may easily pass into insanity, unless counterbalanced by the sobering influence of active outward occupations and interests. It cannot but go ill with any one when he becomes the centre round which his thoughts, feelings, and actions move habitually; and it is certainly a mistake in the cul- ture of mind to develop the emotional part at the expense of the intellect and will. In the religious life, as in the worldly life, the feelings must be kept in due subordination, otherwise it will be in vain to pray to be granted " in health, wealth, and wisdom long to live." For prayer will not compensate for lack of knowledge and lack of will in the govern- ment of the mind and in the conduct of life; and to inculcate or foster a habit of supplication which THE PREVENTION OF INSANITY. 321 is merely a formal or sentimental invocation of help from on high, instead of enforcing the duty of en- lightening the understanding and strengthening the will, is to go methodically to work to undermine the intellect and the will. " I call man's inability to moderate and control the affective or emotional element in his nature Slavery," says Spinoza. " For man under the dominion of his affections is not master of him- self, but is controlled by fate, as it were, so that in seeing and even approving the better course, he nevertheless feels himself constrained to follow the worse." Without doubt, if man could thus attain to freedom by moderating and controlling the affec- tive or emotional element in his nature, he would vastly lessen the sum of insanity upon earth; for he would get rid at one stroke of the so-called moral causes of the disease. Men seldom, if ever, go mad from great intellectual activity, if it be unaccompa- nied by emotional agitation; it is when the feelings are deeply engaged that the stability of the mind is most endangered; and when persons are said to have gone insane, or to have committed suicide, from mental overwork, the truth in nine cases out of ten, if not in all cases, is that anxieties and apprehensions, disappointed ambition, envies and jealousies, the wounds of an exaggerated self-love, or similar heartaches, have been the real causes of their breakdown: and these are causes which all have their footing in an undue self-feeling. De- pressing passions, with the congenial thoughts which 322 RESPONSIBILITY IN MENTAL DISEASE. they call up and keep active in the mind, involve a large expenditure of nerve-force, and if the mind has not gained, by cultivation, an internal power of withdrawing the attention from them and of fixing it on other and more healthy trains of thought, or if favourable external circumstances do not counteract them, aiding the individual to do what he cannot do for himself, there can be in the end but one result— insolvency. Slight excesses of expenditure over income, in vital as in financial matters, must be charged to the capital account, and though each excess may be by itself slight, they are cumulative, and inevitably tell their tale at last. The formation of a character in which the thoughts, feelings, and actions are under the habit- ual guidance of a well-fashioned will, is perhaps the hardest task in the world, being, when accomplished, the highest effort of self-development. It repre- sents the attainment by conscious method of a har- mony of the individual nature in itself, and of the completest harmony between man and nature; a condition in which the individual has succeeded in making the best of himself, of the human nature with which he has to do, and of the world in which he moves and has his being. And assuredly the pursuit of this self-culture through life may be pre- sented to mankind as an aim the attainment of which, rendering them superior to circumstances, will protect them from the injurious operation of those painful emotions which often make shipwreck of the mental health. There is a way, then, hard THE PREVENTION OF INSANITY. 323 and long and weary though it be, of counteracting the third of those powerful causes which I have previously declared to be by much the most influen- tial in the production of insanity. I am unwilling to conclude these desultory re- flections, and to bring this chapter of hints rather than of exposition to an end, without pointing out that the ordinary education of the day systematically leaves undeveloped a vast amount of mentality in the race. It would seem indispensable to a right training of the mind of every child that it should be instructed in the knowledge of the nature of the world in which it has been placed, and of which it is a part. The relations of the earth in the planetary system, the changes which have taken place on its surface through the ages, the elements of which it is formed, and the laws of their combinations and de- compositions, the nature and function of the vege- table and animal life on its surface, the constitution of the human body and mind, and the relations of body and mind to their environment, are subjects on which a vast amount of knowledge has been formu- lated in the various natural sciences. It is strange, when we think of it, that any education which leaves a man ignorant of these things should be deemed an education at all; marvellous that intelli- gent men should be content to go through their lives knowing little more of them than the savages. Apart, however, from the positive duty of man to get the clearest understanding possible of his re- lations with his surroundings, in order to make the 324 RESPONSIBILITY IN MENTAL DISEASE. best of them for the promotion of his own develop- ment, the study and pursuit of the natural sciences furnish a most valuable training of the intellectual faculties, through the steps of observation, generali- sation, abstraction, inductive and deductive reason- ing. No other studies are so well fitted to teach him to observe accurately and to reason correctly; for in the sciences truth is earnestly pursued for its own sake, without regard to whether it may seem useful or not, and without regard to preconceived opinion, or to the claims of authority of any kind ; and in them a conclusion is not accepted as true until it has been subjected to every possible verifi- cation. What is truth if it be not the adequate ex- pression in human thought of sincere relations be- tween man and nature, undergoing modification and increasing in complexity as these relations daily be- come more true, special, and complex in the succes- sive developments of the different sciences ? In these developments, and in the arts founded upon them, nature is undergoing its latest evolution through man, its last and highest product. How then can any one be properly trained to make the best of his powers and to discharge fitly his functions in the world, how can he be educated in the true sense of the word, if he be left without knowledge of natural science ? It will not be denied that there are a great many persons who are quite incapable of sustained atten- tion, accurate observation, and sound reasoning. They are unable to apprehend a question distinctly, THE PREVENTION OF INSANITY. 325 and to fix their attention to it; use words without attaching a definite meaning to them; cherish be- liefs without realising the true nature of what they affirm ; wander in an incoherent way from subjects which they attempt to discuss; believe as their fears, affections, or interests prompt; and mistake prejudices or vague feelings for well-founded con- victions. Now these are intellectual faults which a man cannot be guilty of in gaining a proper knowl- edge of the physical sciences. In such labour he must concentrate his attention, must apprehend clearly the definite meanings of words, must submit his understanding to the facts with humility and perseverance, must patiently follow the successive steps by which the results have been acquired : he can only know in so far as he himself is the humble minister and honest interpreter of nature, or follows in the footsteps of those who, having been success- ful ministers and interpreters of nature, have un- folded the various sciences. In proportion as he deviates, in the study of any science, from this right method, will his knowledge be defective or errone- ous. This being so, it would seem obvious that nothing can be better adapted than such a study to strengthen and develop his intellectual faculties; for it is not merely the knowledge of a particular science which he gains, but he gains a useful habit of mind—a habit of close observation and accurate reasoning, which will serve him well in every other inquiry. He gains not only the power of an in- creased knowledge, but an increased power of gain- 22 326 RESPONSIBILITY IN MENTAL DISEASE. ing knowledge : his intellectual development is along the path of nature's evolution. The more truthfully his thoughts reflect nature in one of her domains, the more easily will other domains of nature be reflected in his mind; for one science thoroughly learnt contains implicitly, quoad the intellectual processes concerned in its attainment, all sciences. His trained understanding makes him the potential master of them all. Nor is the moral nature uninfluenced beneficially by the pursuit of science. It is a labour in which there is but one way of succeeding, and that is through obedience. To penetrate the secrets of nature and to become master of her laws, patience, humility, and veracity are essential qualities. And by veracity in this relation is meant not only the sincere expression of opinion, once formed, but sin- cerity also in the apprehension of truth—a perfect freedom from bias and an entire sincerity of nature in forming and weighing opinions, as well as in uttering them. It may be said, no doubt, that the formation of a character implies more than an in- crease of knowledge by the inductive method, or an increase of the intellectual power which increased knowledge imparts. That is not a matter for dis- cussion now: it is enough for the present purpose to point out that education by the scientific method does demand and therefore strengthen certain quali- ties of the moral nature. And one may take leave to think that, whatever may be the power which best promotes moral development, it can be nothing THE PREVENTION OF INSANITY. but an advantage to an individual to have such a knowledge of the reign of moral law in the domain of human evolution as an inductive method of study will impart to his understanding. It would simplify discussions on education if the truth were distinctly apprehended that morality is not dependent for its existence upon religion, and that men are not dependent only upon revelation for their knowledge of it. Let them realise that nature works through moral laws, as clearly as they realise her operation through physical laws, and they will have as strong a sense or feeling of the folly of dis- obeying the former as they now have of the folly of disobeying the latter. The result must be that morality will obtain as strong a sanction from an inductive method of study as it now has, and has happily long had, from authority, and that an in- creased knowledge will confer an increased feeling of duty and an increased power to perform it. It is difficult to realise the reign of law in our relations with human nature ; for we are unable to look at the matter calmly and objectively as we can in our investigations of physical nature; our sympathies and antipathies as beings of the same kind are necessarily stirred; and we unavoidably mingle our feelings with our apprehensions and conceptions. There will always be therefore a feeling of approbation of right and of disappro- bation of wrong action superadded to the intellec- tual recognition of moral law, such as does not accompany a like obedience to or infraction of 328 RESPONSIBILITY IN MENTAL DISEASE. physical laws. Thus the ethical element, the im- perative mandate, is added to the utilitarian basis. But utilitarianism is an unfortunate word, which, notwithstanding elaborate explanations of what is really meant by it, will continue to give undeserv- edly an ill odour to the theory of morals based upon it. We may justly say undeservedly, because it is certain that morality is a condition of the progress of evolution in the domain of human nature, and that it is therefore in the highest sense utilitarian, as promoting in the long-run the welfare of mankind and of the individuals who constitute mankind. The opponents of utilitarianism will never be per- suaded, however, that it does not mean selfishness— that the theory of it is not to place happiness to the individual as an immediate,end. But the happiness of the race, the exaltation of humanity, is its real end, in ministering to which a right-minded person is to find inward satisfaction, even though the way be through self-denial and suffering; if this be selfishness it is so only in so far as it is selfish for mankind to desire and strive to progress in evolution. The good effects of observance of, and the evil consequence of infraction of, moral law are often remote. That all sin is avenged upon earth is true, but it is not true that a man cannot escape the consequences of his ill-doing; it would be more true to say that mankind cannot escape the conse- quences of a man's ill-doing. In like manner, so far as immediate results are concerned, obedience to moral law, or well-doing, is THE PREVENTION OF INSANITY. 329 often a sacrifice to duty—a self-sacrifice, such as a parent makes for his child and finds his happiness in making ; its ministration to the eventual happi- ness of mankind, much less of the individual, may not be apparent. But the generalisation from ex- perience having been more or less consciously made, and having by accumulation and transmission of effects through generations been fixed in the na- ture as a moral sense or instinct—acquisition hav- ing become endowment here as in other depart- ments of organic development—it is obeyed as a duty by a well-born person, without an intellectual apprehension of its whole operation, and even in scorn of the immediate painful consequences of such obedience.* It is formed as instincts are * Des impressions particulieres, mais constantes et toujours les memes, sont done capable de modifier les dispositions organ- iques et de rendre leurs modifications fixes dans les races. . . . Et si les causes determinantes de l'habitude premiere ne discon- tinued point d'agir pendant la duree de plusieurs generations successives, il se forme une nouvelle nature acquise, laquelle ne peut, a son tour, etre changee, qu'autant que ces memes causes cessent d'agir pendant longtemps. et surtout que des causes differentes viennent d'imprimer a Feconomie animale une autro suite de determinations.—' Rapports du Physique et du Moral de l'Homme.''—P. J. G. Cabanis. The fact that where foxes are much persecuted the young ones show themselves much more cunning and distrustful from the first than old foxes in places where they are not persecuted, was thought by one learned author an absolute demonstration that animals had language; but F. Cuvier explained it by the hereditary transmission of acquired instincts. For other ex- amples of the transmission of acquired faculties see the elaborate Traite Philosophique et Physiologique de l'Heredite 330 RESPONSIBILITY IN MENTAL DISEASE. formed in animals, and then obeyed, as they are obeyed, almost blindly; obedience bringing inward satisfaction, notwithstanding that it may bring ex- ternal privation and suffering. The development of the mental organisation being part of the order of nature, and taking place in accordance with the laws of the nature which surrounds it and of which it is part and product, the moral law in man is the conscious reflection of the moral law in the uni- verse—a result among other results of nature hav- ing become self-conscious in man. And the building up of a moral science by the application of the in- ductive method to the study of moral phenomena, so far from weakening the authority of conscience, cannot fail to strengthen the feeling of duty to do the right and eschew the wrong, by showing plainly how, through the unfailing operation of natural law, the former surely brings good and the latter evil upon mankind. That it should be necessary to enter into argu- ments to prove the moral nature of men to be a proper subject of scientific study, and to set forth the beneficial effect which such a study must have upon the understanding and the moral nature, will probably be thought as extraordinary a thing in the years to come as it seems extraordinary to us now that persons should have had to set forth elaborate Naturelle, by Dr. Prosper Lucas, 1847. But these scattered ob- servations have now found their place, and have been supple- mented by many others, in Mr. Darwin's exposition of his great law of evolution. THE PREVENTION OF INSANITY. 331 reasons in times past to disprove the existence of witchcraft. Meanwhile, it is plain that in neglect- ing a most promising means of mental training, and in thus failing to develop to the utmost all the re- sources of their mental nature, men do not do all that they might do to protect themselves from the inroads of mental derangement. It is, indeed, to the development of the vast amount of undeveloped mentality which there assuredly is among mankmd that we may look with confident hope for the diminution in time to come of the sum of in- sanity upon earth. INDEX. Aoosta, Josephus, on possession by the devil, 37 n. Age, the mental decay of old, 278- 280. Alcohol, the abuse of, 306. Anthony, St., 10. Aphasia, 284; condition of under- standing in, 284; Trousseau on, 285; Dr. W. Ogle, on a case of, 285. Arnold, trial of, 96. Asclepiades, on the treatment of insanity, 8. Astrology, the speculations of, 22. Asylum, lunatic, popular notion of, 1; Mr. Burke's visit to, 2. Aura epileptica, 177, 254. of, 12; sympathy of organs ot, 18. Brain, function of, 16 ; disorder of, 16; organic sympathies of, 18 ; education of, 20 ; patho- logical study of, 166. Browne, Sir Thomas, on heredi- tary influence, 24. Burke, Mr., his visit to a lunatic asylum, 2. Burton, case of, 169. Cabanis, P. J. G., on the trans- mission of acquired faculties, 329 n. Casaubon, Meric, on sin, 27; on madness, 37 n.; on the persist- ence of dream-hallucinations, 270. Capacity, testamentary, 119-129. Cartwright v. Cartwright, case of, 120. Character, formation of, 288, 313, 320. Cheyne, Dr. John, on the preva- lence of insanity, 302 n. Chorea, kinship of, to insanity, 45, 162. Classification of insanity, 71-93. Clissold, Rev. Augustus, on the prophetic spirit, 54 n. 13 BanTcs v. Gvodfellow, case of, 124. Barlow, Reverend John, on the prevention of insanity, 289 n. Bartlett, Judge, on testamentary capacity, 124. Bell, Chief Justice, on the crite- rion of responsibility, 110. Bellingham, trial of, 98. Billman, case of, 220. Bisgrove, case of, 179. Boardman v. Woodman, case, of 111, 115,119,124. Body, the theological contempt 3i 334 RESPONSIBILITY IN MENTAL DISEASE. Cockburn, Chief Justice, on testa- mentary capacity, 123, 124. Code, French penal, 116 ; German penal, 117. Coke, Sir E., on the execution of madmen, 138. Conolly, Dr., on the duty of the medical witness, 92; on suicidal insanity, 149 n.; on homicidal impulse, 158. Consciousness, physical modifica- tions of, 17. Crime, viewed as insanity, 27; hereditary nature of, 30; in im- becility, 71. Criminals, 25-34; the treatment of, 28; the production of, 30; defective organisation of, 31. Cuvier, F., on acquired instincts, 329 n. Delasiauve, on undetected epi- lepsy, 262. Delusions, as the test of insanity, 97,121,122; concealment of, 207, 230; of persecution, 204,210; fu- tility of argument against, 216 ; as causes of homicide, 224, 269 ; influence upon conduct, 232. Dementia, 78; epileptic, 260; se- nile, 273-287; moral, 260, 280. Demoniacal possession, 10. Dew v. Clarice, case of, 121. Dipsomania, 46, 89. Doe, Judge, on tests of responsi- bility, 115, 119. Dreaming, insanity and, 161; per- sistence of hallucinations of, 269. Eccentricity, 59, 290. Echeverria, Dr., on epileptic in- sanity, 253 n.; on epileptic un- consciousness, 256. Education, power and limits of, 20 ; criminal, 29; the true aim of, 309. Emotions as cause of insanity, 302, 312; undue development of, 310. Epilepsy, in criminals, 34; kin- ship to insanity, 44; the neuro- sis of, 168, 177 ; masked, 178, 247; mental prodromata of, 253; peculiar state of consciousness in, 255; symptoms of mania of, 257-260; undetected, 262. Epileptics, religious sentiment in, 261; visions of, 261; imagina- tion of, 261. Erskine, Mr., on delusion as the test of insanity, 97,123. Esquirol, on insanity without de- lusion, 153, 158; on moral in- sanity, 188; on the recurrence of homicidal mania, 221; on the concealment of delusions, 230; on homicidal mania after epi- lepsy, 252. Ettmuller, on insanity without delusion, 151 n. Falret, Jules, on homicidal im- pulse after epilepsy, 251; on the symptoms of epilepsy, 253. Family, degeneration and regen- eration of, 299. Feelings, relation of, to belief, 163; insane, 208, 265 ; the control of, 319. Folie circulaire, 189-191. Foville, Dr., on the condition of mind in monomania, 238. Foxhunting, 313. Griesinger, on the sudden out- break of insanity, 166. INDEX. 335 Hadfield, trial of, 97. Hale, Lord, on partial and total insanity, 95; on witches, 114. Hearden, Dr. J. G., on hereditary predisposition to insanity, 303 n. Hereditary influence, 21-24; Solo- mon on, 23; Jewish recognition of, 24; Sir Thomas Browne on, 24; in the causation of insanity, 304; Dr. Prosper Lucas on, 329 n. Hippocrates, on insanity, 7; on vice, 27. Hoffbauer, his criterion of respon- sibility, 225; criticism of, 227i Homicide, in simple melancholia, 132,141, 200 ; premeditation in, 219 ; epileptic, 246, 263 ; during sleep, 269; after dreams, 270; conduct after, 223. Homicidal impulse, irresistible or unresisted, 173, 208; before, in place of, and after epilepsy, 177, 244-252; the result of insane emotion, 209; the result of delu- sion, 224. Homicidal insanity, 134,135,150- 183; sudden outbreak of, 166; with mental imbecility, 169 ; re- currence of, 221. Howden, Dr. J. C, on the reli- gious sentiment in epileptics, 261 n. Idea, morbid, 159, 160; synergy of, 241. Identity, loss of consciousness of, 282. Idiocy, 71, 95; absence of respon- sibility in, 73. Imbecility, 72; responsibility in, 73; orime in, 73; moral, 192, 260. Impulses, insane, 141. Insane, the manners and appear- ance of, 2, 3; the motives of, 3, 4; distrust of, 4; barbarous treat- ment of, 10; executed as witches, 11; the punishment of, 15, 28, 135, 137; belief in inspiration of, 53. sanity, concealment of, 5; Gre- cian views of, 6, 7, 8; Hippoc- rates on, 7, 8; Asclepiades on treatment of, 8; theological view of, 9,10; metaphysical view of, 13 ; definition of, 15; moral causes and moral treatment of, 16 ; no demarcation between sanity and, 41; kinship between epilepsy and, 44; neuralgia and, 44; chorea and, 45, 162; dipso- mania and, 46; the prophetic mania and, 53; eccentricity and, 60; intellectual, 74; affective, 74, 130-198, 142; classification of, 71-93; hereditary, 85; toxic, 85: idiopathic, 86, 89; sympa- thetic, 86; epileptic, 88, 244- 272 ; of pubescence, 88; of preg- nancy, 88 ; puerperal, 88 ; of lactation, 88 ; climacteric, 89; phthisical, 89; senile, 89, 273- 287; sthenic and asthenic, 89; various forms and phases of, 131; early symptoms of, 132, 139 ; course of, 134 ; homicidal, 134, 150-183; without delusion, 141; sudden outbreak of, 166 ; partial intellectual, 199-243 ; the prevention of, 288-331; heredi- tary transmission of, 296, 302; intemperance as a cause of, 304. Intellect, the development of, 323. Intemperance, a cause of insanity, 804. 336 RESPONSIBILITY IN MENTAL DISEASE. Judges, answers of, to the House of Lords, 101-105. Kleptomania, 88,135. Ladd, Judge, on the dicta of Eng- lish judges, 106; on tests of re- sponsibility, 114. Lamb, Mary, insanity of, 200. Love, the passion of, 298. Life-aims, 315. Lypemania, insanity of, 77, 200. Lucas, Dr. Prosper, on hereditary influence, 329 n. Macarius, St., 10. Mahomet, visions of, 56, 261; the epilepsy of, 57, 261. Mania, the prophetic, 53; general, 75; partial, 75; without delu- sion, 141; epileptic, 245; transi- tory, 247, 262, 265. Mansfield, Lord, on responsibility in insanity, 99. Marc, on homicidal insanity, 156; on masked epilepsy, 179; on concealed insanity, 223. Marriages, wise and unwise, 297- 301. McNaughten, trial of, 101. Medical evidence, 92. Memory, loss of, in senile de- mentia, 274-277; in old age, 279; in apoplexy and fever, 281; in dying, 282. Melancholia, 76, 79; simple, 132, 141; homicide in, 200. Metaphysics, the spirit of, 12,13. Meyer, Ludwig, on a masked epi- lepsy, 179. Mind, relation to body, 9, 12, 15, 17; metaphysical views of, 11; scientific definition of, 15; method of study of, 18; degen- eration of, 300; necessity of ex- ercise of, 316. Monasticism, the spirit of, 9. Monomania, 76, 79; condition of mind in, 236. Morality, the inductive study of, 330. Moral insanity, 142,183-198; Dr. Pilchard on, 63, 69, 187; Es- quirol on, 188; in connection with epilepsy, 191, 260; with imbecility, 192. Moral nature, the development of, 326. Moral responsibility,defective, 26; degrees of, 35; inductive study of, 36. Moral sense, scientific study of, 36; deficiency or absence of, 62; a function of organisation, 64; the origin of, 65; degeneracy of, 67-69. Morel on morbid varieties, 63; on the classification of insanity, 84- 87; on homicidal impulse, 182 n.; on mania as a masked epi- lepsy, 251; on mania transitoria, 266. Morbid idea, relation of, to will, 154, 159, 161. Movements, synergy of, 242. Natural laws, ignorance of, 310; breach of, 311. Natural science, the study of, 323. Nature, individual differences of, 21; inconsistencies of, 313. Neuralgia, kinship to insanity, 44. Neurosis, the criminal, 34; the in- sane, 43, 49, 166, 173; transfor- mation of, 85; the epileptic, 168, 177. INDEX. 337 Nervous diseases, transformation of, 44; functional and organic, 47. Nicholl, Sir John, on testamentary capacity, 121. Paralysis, general, 78; crime in, 81. Peacock v. Lowe, case of, 286. Penzance, Lord, on testamentary capacity, 123. Perley, Chief Justice, on tests of responsibility, 111. Pinel, on insanity without delu- sion, 151; on recurrent homi- cidal mania, 221. Plato, on wickedness, 27; on mad- ness and the prophetic mania, 53. Pownall, Dr., case of, 205. Predisposition, hereditary, 48, 296, 302. Prichard, Dr., on moral insanity, 63, 69, 187. Psychosis, the criminal, 34. Pyromania, 87,173,175. Raptus melancholicus, 202. Ray, Dr., on Lord Mansfield's dic- tum, 99 n. Reformer, the, temperament of, 57. Religion, the misuse of, 319. Responsibility, criterion of, in in- sanity, 14, 95-119 ; in imbe- cility, 73; in partial insanity, 95; Mr. Justice Tracey on, 96; Judge Ladd on, 106; Chief Jus- tice Bell on, 110; Chief Justice Perley on, 111; Judge Doe on, 115, 119; Hoffbauer on, 225; medical doctrine of, 228; discus- sion of medical and legal doc- trines of, 228-243. Self-control in insanity, 291. Self-formation, 315. Self-deception, 314. Shakspeare on responsibility in insanity, 137. Skae, Dr., on the classification of insanity, 87-89; on homicidal impulse, 177. State v. Jones, case of, 106. State v. Pike, case of, 111, 115. State v. Weir, case of, 110. Stevens v. State of Indiana, case of, 111. Smith v. Tibbitt, case of, 123. Somnambulism, 268. Spinoza, on the persistence of dream-hallucinations, 270 ; on the control of the feelings, 321. Stylites, Simeon, 10. Suicide, in simple melancholia, 132. Suicidal insanity, 143-150; heredi- tary transmission of, 141. Swedenborg, epileptic visions of, 261. Sympathy, organic, 17. Temperament, the insane, 49, 59, 173. Theology, the spirit of, 9. Thomson, Bruce, on criminals, 32- 34. Tracey, Justice, on responsibility in insanity, 96. Transformation of nervous dis- eases, 44. Trousseau, on irresistible impulses in epilepsy, 96; on the under- standing in Aphasia, 285, Utilitarianism, 328. Walli», Samuel, case of, 202. 338 RESPONSIBILITY IN MENTAL DISEASE. Wariny v. Waring, case of, 123. Werter, the suicide of, 293. Wharton and Stille' on a case of homicidal insanity, 219. Wightman, Justice, on the desire to be hanged, 170. Will, freedom of, 117,119; power of making a, 119-129; loss of power of, 119, 135; fluctuations of, 160; control of, 289; devel- opment of, 293. Wynne, Sir William, on testamen- tary capacity, 120. Yellowlees, Dr. D., on intemper- ance as a cause of insanity, 305. 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