The Inhibitory Forms of Insanity 
BY 
DR. EUGENE U. CARPENTER 
Consulting Neurologist to the City llospit<\! 
CLEVELAND The Inhibitory Forms of Insanity 
BY DR. EUGENE G. CARPENTER, CLEVELAND 
Consulting Neurologist to the City Hospital 
|T IS to be hoped this Society which has so kindly ladened me with 
1 the subject of this paper will not expect new revelations. “Casi- 
bon’s key to all mythologies” has been assiduously sought for, but I 
fear not found. It is an attempt not to bring fresh facts, but to evolve 
the truth out of a number of those we already have in our possession, 
hrom a heap of old brick lying in disorder and confusion may be 
built a secure foundation, if not a substantial edifice. 
Many of the fixed principles of today lay hidden for ages before 
emanating from the jumbled mass of truth and error surrounding 
them. Even when the fact has been observed, it often takes centu- 
ries before it can be extricated from its confused environment and 
given its proper place in formulated knowledge. This has been the 
history, briefly stated, of not a few of our most positive scientific 
principles, principles which will abide through all time. 
The subject of insanity which we will discuss tonight has at one 
time been considered by savants as a demoniacal possession, at anoth- 
er a blessing sent by God. Today in Egypt the insane person is 
largely cared for at home, and on account of his being regarded a sa- 
cred person he receives the kindest care and consideration by his 
friends and relatives. 
Our study at this assembly is not the whole domain of insanity, 
nor that part which relates to the easily recognized forms. It must 
have reference to those more obscure forms, the borderland forms, 
those which from their nature and characteristics give rise to medi- 
co-legal discussion. We know daylight from darkness, but we do 
not know where the one begins and the other leaves off. We recog- 
nize the different colors, but we cannot in the spectrum fix the lim- 
itations of each. We are able to say that disease exists in a human 
body, but we cannot always say where the physiological has ceased 
and the pathological has begun. In no disease does this so truly 
obtain as in the intermediate forms of insanity. And because it is a 
fact that it is most difficult and at times if not at all but impossible to_ 
Read before the Medico-Legal Section of the duyahogQ, Medical Society, Fed. 
18th, i8cyj iiURGcC i GCN-hAL'i 0.*i 2 
draw a fixed and fast line between them, they have become the “bone 
of contention” in our courts and will be until we recognize that there 
is a standard of normality in the sane and the many uniform short- 
comings in one truly insane. I claim individually that with know- 
ledge gleaned from living with the insane and sonsidering these va- 
rious obscure forms from the various standpoints of their antecedents, 
life history, and make-up of their entire organization, anatomically, 
physiologically and mentally, one can determine almost the truth of 
their real condition. 
In styling them intermediate states, allusion is made to the so- 
called moral, emotional, partial, transitory, homicidal and impulsive 
forms of insanity. 
Moral insanity has been a medico-legal enigma for a hundred 
years. It had its origin at the time of the French revolution, when 
it was created for the purpose of excusing many of the slaughters 
that took place at that time. Since then it has been taken up by some 
authors who gave it recognition as a special form of insanity, and as 
a result it has been a point at issue between doctors and lawyers of 
different schools of opinion. Too frequently and most unjustly has 
it been used as a means to screen criminals from the responsibility 
of their crimes. The term has been used at times interchangeably, 
confusedly and erroneously with various forms of unquestioned mental 
disease. As a form in itself disassociated from other and previous 
evidences of mental disease I do not believe in it. As I have said, it is 
mentioned by most writers. Rv some, as Ray, Bucknill and Tuke, 
strong ground is taken. In the sense that a mere immoral act devoid 
of other evidences may be proof of it, I do not believe such a thing 
exists. In all the bibliography on the subject I cannot find the de- 
scription of such cases. The books are filled with citations of cases 
of moral insanity, but invariably there goes with it previous or sub- 
sequent evidence of morbid mentation or physical evidence of it. In 
the later sense I believe with Prof. Kraft-Fbing it might be admitted 
for clinical purposes only, but I must regard all these so called types 
as but confusing to the student and alienist. I regard them but 
phases of different well recognized forms of insanity. They merely 
express a prominent feature or trait of the insane condition. Funda- 
mentally they are not separate and distinct brain diseases. With just 3 
as much wisdom we might say of typhoid fever, delirious, nervous, 
tympanitic, or febrile typhoid. 
The day is dawning when the microscope will reveal the truth to 
a certainty what pathological changes occur in the commoner forms 
of insanity, and I doubt when science has enabled us to prove the 
truth, if we shall see different cell changes in all these so called forms. 
The pathology of brain diseases gives us no evidence that these forms 
are dependent upon limited lesions. On the other hand the post 
mortem table does frequently reveal extensive departures of the tis- 
sues from the normal. 
In the case of the U. S. vs. Charles J. Guiteau, Dr. A. E. Mc- 
Donald, who had had a large experience with the insane and criminal 
classes in the New York City institutions, testified as follows: 
“Emotional insanity is insanity which effects only the emotions 
and leaves the intellectual and moral nature and everything else, for 
that matter, perfectly intact. I have never seen a case of such insanity. 
Partial insanity is the name of a supposed form where a part of the man 
is affected with the disease of insanity, while the rest is perfectly 
healthy. I have never seen any case of partial insanity. Mono-mania 
is the same thing. That supposes or presupposes the division of a 
man’s brain into compartments and that there is one little compart- 
ment that presides over some certain action and may be diseased and 
the rest all right; that one part governing honesty may be diseased and 
he steals; that he may set fire to houses and be all right in every other 
respect. I do not believe in such insanity,, and / have never seen such 
a case. Transitory insanity is the name given to a certain supposed 
form, under which an act of violence is committed; that act being the 
sole and only evidence of insanity; the man being sane up to the mo- 
ment of committing it and sane the moment afterwards. Insane at the 
time of the act; insanity being shown only by the act. / have never 
seen such a case. Moral insanity is supposed to describe a disease 
where the man’s intellect and reason could be perfectly sane, normal, 
proper and healthy, and yet his normal nature so diseased that he 
would commit these acts of violence. I do not mean to say there 
is no such thing as insanity showing itself in the disturbance of the 
moral nature, but I do say there is no such disease as moral insanity 
confined to the moral nature.” 4 
Dr. Allen McLane Hamilton, author of an excellent treatise upon 
jurisprudence, in this trial was asked by the defense: 
“Is it true that insanity may lurk in a person for years without 
being noticed, and break out afterwards in the shape of crime as the 
result of insanity?” 
Answer. “I do not know what you mean by lurking in a person. 
I do not think there are many persons who have homicidal tendencies 
that do not show insanity.” 
Question. “That is, you think as soon as the homicidal tenden- 
cies are conceived or born in a person’s mind, it is immediately in- 
fluenced?” 
Answer. “I do.” 
Question. “May there be a predisposition to insanity, or what is 
ordinarily called hereditary taint, existing for years unnoticed, and 
then break out in a homicidal tendency? 
Answer. “With other manifestations. I should not make my 
diagnosis of insanity simply upon the fact that a man killed another.” 
Dr. Ray is one of the staunchest defenders of moral insanity as a 
special form. After a resume of the ground taken by its enemies, es- 
pecially against the improbability of a single act proving insanity, he 
says: "We admit with them that the single criminal act unaccom- 
panied by other suspicious circumstances may sometimes be ver\ 
unsatisfactory proof of insanity, but we apprehend that such cases are 
very infrequent. When such an act is really the result of insanity, we 
can usually find in the antecedent or subsequent history of the patient, 
if we will carefully look for it, some corroborating proof of its pres- 
ence. Even without it the act may be of such a nature as to impel us 
to refer it to mental disease. When a woman previously distinguished 
for every virtue, kills her darling child, am I obliged to stifle my in- 
stinctive convictions of her insanity merely because no other symp- 
tom of mental disease has been witnessed? In such a case we may be 
sure science and humanity render no discrepant testimony.” 
Bucknill and Tuke have also been regarded as champions of moral 
insanity, but in their 1879 edition is found at the close of their article 
on “Moral or Emotional Insanity Proper,” these words: “At the 
same time we hold that the cases are rare in which disorder of the in- 
tellectual faculties cannot sooner or later be discovered by careful ob- 
servation, and to this end the attention of the observer ought to be carefully directed in each case. And whatever then may be thought 
of extreme theories which have been advanced in regard to moral in- 
sanity, we agree with Griesinger that ‘It should be constantly borne in 
mind that an individual may talk quite rationally and at the same 
time show by his acts and by his conduct, and even by what he does 
not do, that he is mentally deranged.’ ” 
As liberal an authority as Maudsley, in his “Pathology of Mind,” 
under the heading of Moral Insanity, says: “When moral insanity 
exists by itself and constitutes the disease as it may do, it would be 
wrong to assume that a particular vicious act or crime or even a series 
of vicious acts proves its existence. No competent physician ever does 
that, although lawyers and the general public are apt to think he does 
and to charge him, therefore, with confounding vice with madness. 
In the previous history of the patient there will be evidence of a suf- 
ficient cause of disease having been followed by an entire change of 
manner, feeling and acting. The vicious act or crime will be traceable 
through a chain of symptoms to disease as cause, as the acts of the 
sane man are traced to or deduced from his desires or motives." 
Dr. Pritchard, who first called special attention to this form of 
insanity, holds there is often a strong hereditary tendency to insanity; 
the individual has previously suffered from an attack of madness of 
a decided character. There has been some great moral shock, as a loss 
of fortune; or there has been some severe physical shock, as an attack 
of paralysis or epilepsy or some inflammatory disorder, which has 
produced some change in the habitual state of the constitution. In 
all of these cases there has been a change in the temper and habits." 
A still more modern writer, Dr. Savage, of London, concludes. 
“I should hesitate before accepting impulse, unless I had evidence of 
insanity in other members of the family, or neuroses such as neuralgia 
or epilepsy in the patient himself.” 
After an experience now of twelve years in which I have come in 
contact with the insane both in asylum and private practice, I must 
say I cannot testify to having seen a single case of insanity character- 
ized by impulsiveness but what there were additional symptoms of 
the disease present. 
Dr. Maudsley would class these forms in which insanity is mani- 
fested by acts, without delusions and hallucinations, as affective in- 
sanity. This has not been accepted widely, however, as it does not ex- 6 
plain any condition particularly, beyond that the acts have for their 
basis a morbid state of feelings. 
Dr. Clouston, of Edinburgh, whose work on “Mental Diseases” 
holds a front place of all the works on the subject extant, would call 
all these impulsive forms as inhibitory forms or “Inhibitory Insanity. ” 
You will now say we are still as deep in the mud as we were in 
the mire. I do not myself approve of such a form, but I do think it 
admissable as expressing a pathological condition which lies at the 
base of all these forms of insanity expressed by impulsive acts. This 
authority holds “the physiological word ‘inhibitory’ can be used syn- 
onymously with the psychological and ethical expression ‘self-control’ 
or with the ‘will’ when exercised in certain directions.” 
We have observed the function very early in children. While 
they are yet young they will refrain from the temptation of handling- 
articles of bricabrac in a room after having once been admonished not 
to do so. All men possess it in some degree ; some more, and others 
less. Very few men possess it in its perfection. And yet all sane 
men are supposed to have it sufficiently to enable them to control their 
apimal desires, and yet to a greater extent to prevent them from com- 
mitting murder. It is the highest of the mental functions. It is that 
which marks man the “paragon of animals” and raises him above their 
low estate, ft is the supremest expression of his development. It is 
the last product of his evolution and the first of his dissolution. One 
of the first evidences of most forms of mental disease is the loss of self- 
control. I believe myself that in all cases of loss of inhibition, where 
it manifests itself by impulsiveness, they can find place in one of the 
following forms of insanity: Acute, chronic or delusional mania, mel- 
ancholia, epilepsy, paranoia, paresis, alcoholism, idocy and imbe- 
cility, or among the degenerate. We must insist that inhibition is a 
function or quality of brain cells. While there is no positive proof of 
inhibitory centers, there is mental inhibition, and a function always 
implies an organ. / do not believe in functional mental disease. 1 
believe them all to depend upon brain cell action in an unhealthy state. 
That weak restraining power in the sane to be acquired or is due 
to innate weakness through heredity. That deficiency of control in 
the insane is due to either disorganization of brain cell through disease 
or defective brain cell as found in those born deficient. I believe the 
prominence which the moral, the emotional, or impulsive feature may 7 
hold In a given case of insanity is an expression of defective inhibi- 
tion : and that as it exists in different degrees of strength in the same, 
so does it differ in different degrees of weakness in the insane. Dr. 
Clonston says: “Sufficient power of self-control should be the es- 
sence and legal test of insanity if we had any means of estimating it ac- 
curately.” This, T believe, to be the common ground upon which we 
as medical men and jurists can unite. That it is the tendency of the 
law to keep apace with the science of this subject is forecast by noting 
the changes from time to time during the past three centuries as to 
what the test of responsibility should be. 
Judge Tracv held that unless a criminal was as irresponsible as a 
wild beast he should suffer punishment. 
Lord Mansfield held to the test of right and wrong. The twelve 
judges in the McNauton case that a knowledge of right and wrong 
relative to the act committed be the true legal test. 
Lord Denman that the presence of delusion was the test. 
Lord Moncreiff that a man’s habit and repute among his fellow- 
men who knew him well was the proper legal test. 
Finally, Mr. Justice Stephen would make the man’s power of con- 
troling his actions the test. With this view all medical men can agree. 
He says: “The proposition T have to maintain and explain is, that if 
it is not, it ought to be the law in England that no act is a crime if the 
person who does it is, at the time when it is done, prevented either by 
defective mental power or bv anv disease affecting his mind from con- 
trolling his own conduct, unless the absence of the power to control 
has been produced by his own fault. 
Tn conclusion, T hold that in every instance where the question of 
insanity arises as connected with crime, it ought to be submitted to 
the judgment of a commission of two medical men and a lawyer who 
shall examine the person and file their report with the Judge 
which shall be used only as evidence. As it stands now, 
both doctors and lawyers are looked upon with sus- 
picion: the first as guilty of drawing out fine spun theories to screen 
the criminal, and the other as willing to resort to any advantage in or- 
der to punish the miscreant, sane or insane. As it stands, our statutes 
are inadequate to meet the exigencies of these cases, and until cor- 
rected the same discordance will continue between the physicians on the one hand, who will look upon some criminals as being subjects for 
treatment, while the lawyers look upon all as subjects for condemna- 
tion. 
LITERATURE. 
Ray’s Jurisprudence of Insanity ; Maudsley, Pathology of the 
Mind ; Bucknill and Tuke, Psychological Medicine ; Clouston, 
Mental Disease; Savage, London, Insanity ; Kraft Ebing, Psy- 
chiatric ; Mercier, Sanity and Insanity ; Kraepelin, Psychiatrie. 
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