THE MODERN CRANK and Mental Responsibility, BY- John IP union. N1. 1 )., of KANSAS CITY, MO. Reprinted from the TRI-STATE MEDICAL JOURNAL, February and March, 1S94. THE MODERN CRANK AND MENTAL RESPONSIBILITY. By John PUNTON, M. D., of Kansas City, Mo. Professor of Nervous and Mental Diseases in University Medical College; Special Lecturer in the Western Dental College; Neurologist to All Saints; Scarritt Bible and Training School; K. C., Fort Scott & Memphis R. R. Hospitals. &c., Ac. THE study of mental science is based on physiological principles and recognizes the brain as the sole organ of the mind and its functions as being multiform. It is unnecessary to discuss the question how we know that the mind is made manifest through the brain, suffice it to say that physiological, as well as pathological facts, clearly demonstrate that the brain is the seat of all normal as well as abnormal mental action and that the normal operations of the mind depend upon the normal integrity of the brain, although they are to some extent influenced by the state of other organs of the body in disease. Recognizing the brain as the sole organ of mind, we find that it is composed of a number of organs each of which is endowed with special functions, activities, or powers capable of acting independently, although intimately connected and in all continuous mental processes are brought more or less into relative and consecutive action. The brain, therefore, being the recognized dominant organ of the body affecting all its tissues, controlling all its functions, and to some extent, at least, regulating all its energies, its study becomes of the highest value. When any other organ of the body is affected by disease it is after all merely a part of the man that suffers, but when the convolutions of the brain are disordered, mal-nourished or mal- formed, then it is the man himself that is affected ; for every other part of the body subserves the brain, and all the functions of the brain are subservient to the mind. The one dominates the other as does steam the engine; indeed, as Clouston says: “Looked at from an evolutional point of view everything that lives tends towards mentalization and all the nervous organs of every type of animal life find their acme in the human brain convolutions.” The brain, like any other organ of the body, is liable to disease and even more so because of its extreme delicacy of structure and simplicity of function. All disease of the brain, however, does not necessarily constitute insanity, but if the brain becomes diseased the mind is invariably affected, since healthy mental operations depend entirely on .the normal integrity of the brain. In the present state of our knowledge it is almost impossible to define satisfactorily all that is embraced in the term Insanity. Each writer, therefore, in defining the term, has done so according to his own particular view of the subject, hence they are as varied as the features of our faces. According to one it consists in such disorganization or degeneration of the nervous substance as to render the exercise of reason impossible. Another regards it as being a disorder of the reason itself, while a third states that it consists in a perversion or destruction of the soul or moral, part of our nature. The prevailing view of scientists, however, is that insanity is q symptom or expression of disease of the brain affecting the mind, 2 It is useless to discuss the relative merits of any theory or definition set forth ; suffice it to say that all are now agreed that insanity results from some disordered state of the brain. The study of insanity, therefore, is pursued on precisely the same plan as that required for any other disease of a bodily organ and is consequently based on rational physiological principles. In a word, the physician must simply accept the facts of physiology and regard man as a whole in his compound nature, viz: body, soul and spirit. This method of investigating mental diseases Dr. Maudesley terms the inductive method by which the physician simply becomes the servant and interpreter of nature. The very first step, therefore, is to form in our own minds a standard of mental health, or normal mind, and to do this we are compelled to go to nature and study man as he exists in nature in all stages of his development. This is really the clinical mode of studying mental disease on a physiological basis. The student, therefore, studies normal mind as a form of brain energy having relationship to every part of the body ; and the physician investigates mental disorders in the same observational and inductive way as he does disease of other organs such as the heart, lungs, liver, kidneys, etc. From this point of view the student soon discovers that normal mind, or normal mental operations, differs enormously in different individuals, in different sexes, stages of life and races. He also discovers that it is not a fixed standard but presents a wide area of abstract problems relating to age, sex, heredity, race, education, period of life, temperament, occupation, habits, etc., etc. In a certain sense it may be said, that every person sets up his own standard of mental health which is largely influenced by all the above circumstances. In individuals whose brains are well formed, free from structural changes, and are nourished with a due supply neither exces- sive nor deficient of healthy blood, the faculties of the mind are manifested in a manner common to mankind in general. Slight changes in the forma- tion of the brain, or impairment of its proper nutrition, induce corresponding changes in the several parts of the mind which it subserves, or in it as a whole; and, as no two brains are exactly alike, so no two persons are exactly alike in their mental processes. So long, however, as the deviations in this or that direction are not directly at variance with the average human mind, the individual is con- sidered sane. If these deviations are directly at variance he is said to be insane. Now the one assumes as the basis of all its enactments that all men have their inherent power to do certain things, and avoid, doing other things that would be inconsistent with the well-being of society, or the safety, or comfort of their fellow men. But we must remember that, within the limits of health, marked irregularities are met with in different persons, constituting different peculiar mental types. For instance, some persons are noted for never perceiving things as the majority of people perceive them. Others have their emotions individually or deficiently developed, while still others are weak in their judgment or defective in memory, feeble in their powers of application and vacillating in their opinions. Others again are lacking in their volitional powers, in their ability to perform certain acts, to refrain from others, or to follow a (definite cause or action which their intellect tells them 3 is expedient and wise. Persons, therefore, whose minds deviate in some one or more notable respects from the ordinary standards, but yet whose mental processes are not directly at variance with that standard, are said to be eccentric or cranky. You are all doubtless familiar with the class of persons to which 1 allude, for every community has its cranks, yet we can hardly accuse them of being actually insane. The numerous peculiar mental characteristics belongingto human nature have even given rise to a popular belief that all persons are more or less insane. The falsity of the position, however, can easily be demonstrated, although we are compelled to admit that in the more marked forms of eccentricity it is not always easy to draw the line between sanity and insanity. That there is a marked difference between the two no one can deny; for, in mere eccentricity, the intellectual faculties are not prevented and with the exception of the judgment, are not even defective. It is neverthe- less true that it manifests itself in a variety of ways, for instance one from the judgment is strong and there is an excess of individuality with great independence of thought and action. In another, and weaker form, and which is the most common sequel to insanity, the practical judgment is invariably weak and the character is marked by obstinacy or fickleness beside unaccountable states of marked emotion which are remarkable for their strangeness rather than their force, as Bucknell and Tuke have so ably demonstrated. Then, again, the perverted emotions of the eccentric man are feeble in comparison with those of the lunatic, and it is seldom that they result in offences against the law. The propensities are also normal and the countenance, demeanor, and the state of muscular activity, are devoid of the ordinary signs of insanity. Hammond says that in eccentricity its manifestations are according to a fixed system—are not founded on delusions, and are generally excited by these emotions or desires which are reflected back to the individual, such as pride, variety, the love of approbation or notoriety. In its most marked forms such persons stand upon the very verge of insanity with a decided predisposition to mental disease, and, ordinarily, if they do not pass the physiological limit it is for want of a sufficient exciting cause. These are the forms which are now attracting so much attention, as they constitute the material from which the modern homicidal crank or maniac is evolved, and are described as suffering from the Neurotic Diathesis or Insane Tem- perament. Such persons are characterized by striking peculiarities, eccen- tricities, originalities in useless ways, oddities, disproportionate developments and nonconformities to general rules, these things not amounting to mental disease, in any correct sense, and yet, usually by heredity closely allied to it, or, by successive steps of degeneration, ending in it sooner or later. Instances of eccentricity passing into positive insanity are common enough, and inquiry will frequently disclose the fact that the life of the now insane person has been marked by strange conduct in both speech and action for months and years before becoming sufficiently affected with cerebral, disease to produce mental aberration. Under favorable circum- stances this fatal heritage, or acquired defect, may disclose itself only in harmless acts or singular caprices; but if the individual is placed under 4 conditions of great excitement, or subjected to severe mental and physical strains, the inherent propensities are apt to mature and develop and finally display themselves in impulsive or premeditated acts of violence such as suicide or even murder. It is possible, therefore, to class such persons into two great divisions, viz : First, Those who are apparently harmless. Second, Those who are positively dangerous. Instances of the former becoming the latter, however, are quite common. Indeed it can now be easily demonstrated that the modern homicidal crank is evolved in a peculiar but definitely progressive manner and presents certain well-defined clinical characteristics which in themselves constitute distinctly marked entities. This tendency to homicide, however, while not always a special morbid entity with the insane, for, in a general way it may truly be said that every maniac may at a given moment become dangerous, nevertheless these constitute exceptional cases and are indeed accidents for we are compelled to recognize the fact that in certain clinical circumstances the insane are impelled to commit murder, and these pathologi- cal circumstances can be traced and even classified. Hence we are justified in agreeing with Dr. Camuset, of France, when he advances the principle “That tendency to homicide is not a common, unimportant symptom which can be observed in all kinds of mental affection, but on the contrary that this tendency is a symptom belonging to certain psychoses and manifests itself in certain well determined clinical circumstances.” It has been proved beyond doubt that the type of mental disease in which homicide is more frequently met with than any other is monomania. The variety of insanity has several synonyms, the chief of which is paranoia. To Morel belongs the credit of having first pointed out to the profession its chief distinctive feature, viz : being marked by fixed and systematized delusion. The ordinary form of this type of mental disease is for the delusions which accompany it to refer to one particular subject, or set of subjects, or for the patient to be morbid in a particular direction of intel- lect, or feeling, while he is sound in most other directions. These delusions admit of classification as follows : First, Those of usual greatness, or pride, or grandeur. Second, Those of unseen and impossible agencies. Third, Those of unfounded suspicions of persecution. In the first they may believe themselves kings or queens, or the possessors of fine mansions, &c., &c. In the second they sometimes believe themselves electrified, mesmerized or overcome by noxious gases, or imagine that telephones are talking to them through the walls or roof. While in the third form they attribute their troubles to the malevolence of real persons who they claim plot against them, or have evil designs on them, such as poisoning their food, or persecuting them, in every conceivable way. This variety is similar to the preceding with this exception, that they do not present so great a departure from soundness of mind and do not regard their annoyance so proceeding from impossible sources or unseen agents, but are usually referred to actual incidents of real persons. Monomania, or Paranoia 5 is defined by Spitzka as follows: “Paranoia is a chronic form of insanity based on acquired or transmitted neuro-anomalies of the conceptional sphere, which, while they do not destructively involve the entire mental mechanism, dominate it.” It will thus be seen that Monomania or Paranoia is, in most instances, based on an inherited taint or transmitted neurotic vice, but may also develop after any deep or sudden injury to the nervous system. We therefore recognize in this, as well as in other varieties of insanity, two large classes of etiological factors which may exist independ- ently, or in combination, and are the more remarkable inasmuch as they produce certain special characteristics which would seem to belong only to Paranoia. These causative factors are usually divided into (1) Those which are congenital and (2) Those which are acquired. In an elaborate paper on Homicidal Mania by Dr. Camuset, of France, the author claims that it is in the mania of persecution that we most fre- quently find homicidal tendencies, and proves his assertion in a masterly manner by the presentation of facts supported by actual clinical observation and study. Under this name he says two distinct morbid entities are desig- nated in France, viz : First, The mania of persecution of Lassegue. Second, The mania of persecution of Falret. Both of these present several features in common, but others in particu- lar, which differentiate them. MANIA OF LASSEGUE. For instance, the subjects of the first class usually belong to those individuals whose insanity has been acquired by reason of their dissipated habits or irregular lives. It can also be demonstrated that the evolution of their insanity is perfected by progressive steps which comprise three periods or stages. In the first, the person may appear to his friends or neighbors as being peculiar in his manners, and, beside entertaining strange ideas, having his mind preoccupied, as it were, with either foolish or appar- ently scientific subjects. The duration of this period varies in different individuals. The second period is marked by systematized, ideas of perse- cution or delusions accompanied with hallucinations. He begins to think he is being persecuted by imaginary enemies. He interprets everything that happens to him in the spirit of persecution, and fastens the apparent wrong on some real personal friend, acquaintance, or even a stranger. He thinks he knows his enemy and plans to get rid of him by killing him. This determination is usually guided by logic, as his mental faculties are in a great measure preserved, and, with the exception of his delirious ideas, he reasons soundly. His plot, which has been premeditated possibly for months, and even years, is finally carried out, and he commits the murder of his supposed enemy. It is possible that up to this time he was considered harmless, or at least anything but insane by his friends, because, during both these periods, he may have dissimulated his real condition by pursuing his usual daily occupation. In the third period, which is sometimes wanting, ideas of grandeur add themselves to his preceding troubles. Thus it appears that his evolution is marked by successive gradual stages until homicidal mania is fully developed and the murder committed. 6 Then, perhaps, for the first time, is his true mental condition recognized, and his dangerous propensities understood. MANIA OF FALRET. In reference to the characteristics belonging to the second class, or Mania of Falret, we find that these individuals belong usually to the congenital or predisposed subjects, having received from their ancestors certain morbid neuropathic taints which are susceptible of development on the slightest provocation. By virtue of such inheritance they appear intellectually degenerated, and, in consequence of the excessive exagger- ation of their defective character, are naturally envious, suspicious and proud. Like the preceding class, they reach mania progressively and interpret all that happens to them in a sense of persecution, although they have no hallucinations. Believing themselves persecuted, they soon become persecutors. They select the person, who, according to their own story, has done them the greatest injury, and this selection is often guided by some real incident whose bearing they misconstrue. These persons have no hallucination or delusion in the true sense, but have lost their mental equilibrium. Another feature which is conspicious, and which differentiates them from other types, is the fact that if they commit murder it is done impulsively, that is, on the spur of the moment. The idea of taking life seems to impose itself on them, either under the influence of passion or spontaneously, without any other reason than a special pathological con- dition of the brain. It may even happen that impulse and act may be unconscious, and when accomplished, the perpetrator may not even keep the least remem- brance of it. Such are the murders among others committed by certain epileptics. These same persons, however, can sometimes invent false accusations, which are cleverly combined, and skillfully direct schemes and enterprises which are commonly termed black-mailing. In recapitulation, therefore, we find the following characteristics in Paranoia : First, That in both these described conditions the insanity is of ancient date at the time homicidal mania is reached. Second, That the insanity is reached by progressive steps like logical deductions of delicious conceptions. Third, That the homicidal tendencies do not show themselves at the beginning of the affection, but in an advanced stage. Fourth, That in the Lassegue type the homicide is premeditated, and governed, to some extent, by a reasoning logic. Fifth, That in the Falret type the murder is committed under a sudden impulse and premeditated, and may be unconsciously done. Sixth, That Homicide is most frequent in the Lassegue type, although it usually accompanies both. Seventh, That the delusions are systematized and fixed in the Lassegue type, but not present to such a degree, if at all, in the Falret type. Many of these persecutors have killed, under the influence of their malady, many prominent persons, and perhaps the latest is the recent shocking murder of Mayor Harrison, of Chicago. In analyzing the pub- 7 lished reports, up to date (November 21, 1893,) it is clear that Prender- gast, the murderer, is insane, and that his insanity is ot ancient date. We also recognize that the murder was premeditated and planned by an apparently reasoning logic. That the murderer had homicidal tendencies long before he carried out his designs, and that he had delusions of persecu- tion no one will deny, and these were fixed and systematized. He even dissimulated his real condition by attending to his daily vocation, and was thus considered harmless. When these facts are all connected and examined in the light of .the latest scientific medical knowledge as advanced by our worthy French Colleagues as well as American Alienists, we are impelled to recognize Prendergast as a Paranoiac, belonging to that form of mania which is accompanied with fixed and systematized delusions of persecution. MENTAL RESPONSIBILITY. It is very, evident that the legal responsibility of such individuals is a subject fraught with numerous serious abstract problems pertaining to both law and medicine. The question of responsibility in criminal cases is one well worth the closest study, for we are not to consider the subject in any sentimental manner, nor build up a flimsy and utopian theory with which to excuse those in whom it is difficult to find marked evidence of intellectual degeneracy or mental disease. In legal medicine it is not sufficient to affirm that a given murder has been committed under the influence of madness, but it is necessary to prove that the homicide in question constitutes a part of a well-known morbid state, which is characterized by certain definite clinical phenomena, being the result of a disordered condition of the brain. It is also necessary to establish its genesis, if possible, by tracing its etiological factors. The function of the physician, therefore, in all cases, is to ascertain the true mental condition of the person accused of crime; to protect him from punishment if he is really “insane and consequently” irresponsible—to protect society from the injury of admitting insanity as a plea when the act is really criminal; and finally to avoid discharging those who are foynd “not guilty” on the ground of insanity, until they are perfectly restored to mental health. That there has ever been a tendency towards a divergence of view between medical men and lawyers in regard to the amount and kind of mental disease that should exempt from punishment for crime, cannot be denied. This is largely due to the fact that these are usually cases where vice, crime and mental disease are mixed up in a dreadfully puzzling manner, and we are all compelled to admit that, so far, we have no definite test for detecting minute amounts of mental disturbance. The greatest skill, tact, knowledge, and sound judgment, are therefore needed on the part of the physician and lawyer to demonstrate the actual facts as well as mental condition of the accused. The presence of the basic element of disease is therefore the indispensible prerequisite to any legal recognition of insanity, and no other form of insanity than that which springs from bodily disease is known to law. It is needless to add that insanity, under whatever manner it may be recognized in medicine, has but one designation in law, and that designation is founded upon the fact that mental incompetency 8 exists in such permanent form that there is continuous enslavement, or duress, of the reasoning faculties. Consequently, every act performed by such a mind, which involves responsibility at law is voidable, although not necessarily void. The legal test of insanity in criminal cases is usually the knowledge of right and wrong—that is to say, a criminal is considered to have been sane when he committed the crime, if he then knew the nature and quality of the act, and that it was wrong. This right and wrong test,, therefore, is the one that is usually applied by the majority of legal author- ities both in England and America, but it is not the oniy one that is or has been used. “In England,” Clouston says, “Judge Tracy held that except a criminal was irresponsible as a wild beast he should suffer punishment. Lord Mansfield held that a knowledge of right and wrong was the test. Lord Moncrieff has laid it down that a man’s habit and reputation as to sanity among his fellow men who knew him well should determine his legal responsibility for any crime committed. At last the new criminal code of Justice Stephens proposes to make the man’s power of controlling his actions the test, and with that view every medical man will agree.” He says: “The proposition which I have to maintain, and explain, is, that if it is not, it ought to be the law of England that no act is a crime if the per- son who does it, at the time it is done, is prevented, either by the defective mental power, or by any disease affecting his mind, from controlling his own conduct, unless the absence of the power to control has been produced by his own default.” The American decisions in regard to criminal responsi- bility are practically alike, and the question of the knowledge of right and wrong seems to be the one the jury is called upon to decide. It is very evident that the law of the land should be so changed as to conform witk the latest acts in medical science, for it takes but little study to learn that there are numberless cases where the persons arc clearly irresponsible, yet know right from wrong. Hence, the law as it now stands, is diametrically opposed to the teaching of pathology when it rules it is only when mental disease produces incapacity to distinguish between right and wrong that immunity from the penal consequences is admitted. To be in strict accord with medical teaching, the law should recognize the absence of the power of self-control and introduce this in the interests of humanity and justice as an element of responsibility when it has been destroyed or impaired by mental disease. The study of Insanity, together with its pathological demonstrations, abundantly establishes the fact that there are forms of mental disease in which the patient is perfectly aware that the act he is about to do is wrong, and yet is unable to control the impulse owing to a diseased functioning of the brain. In a recent paper on Legal Responsibility by L. C. Gray, of New York, published in the Review of Insatiity for Sept., ’93 the doctor very aptly calls attention to the fact “That great injustice is likely to be done to insane people by basing the view of insanity upon the proposition that if a man is able to understand the nature, quality and consequences of an act, he is legally responsible for such an act. The question of legal responsibility, the doctor said, should be determined, not by laws, but by facts. He also calls attention to the fact that in Paranoia the reasoning powers and the memory are usually intact, yet the patient has undeniable hallucinations and delus- ions under the influence of which he commits acts for which he should not be held legally responsible. To support his views the doctor cites the case of the Paranoiac Dougherty, who imagined himself the lover of Mary Anderson, and, under his delusions of persecution, murdered Dr. Lloyd, of the Flatbush Asylum, whom, he thought, conspired against him by keeping him from her. The only safe test, he adds, of legal responsibility is an answer to the simple question: Is he insane} If he is, then he is not legally responsible and this question can only be decided by competent physicians and not by fine-spun theories of lawyers. Common sense must be applied to such cases rather than metaphysical definitions of mental aberration.” The question of Prophylaxis could be introduced at this point with propriety, but as my paper is already too lengthy, I must refrain from this important subject, suffice it to say the scriptural promulgation, that “the iniquities of the father shall visit the children unto the third and fourth generations” is even more potent to-day than ever before. Who can deny the fact that the greatest need of our country to-day, from whatever stand- point we view it, is more healthy men and women, and the quickest and surest way to secure these is by wisely regulating matrimony. As physicians, we are well acquainted with the laws of heredity, hence you will understand me when 1 say that 1 believe in certain cases and to some extent, at least, marriages should be governed by law ; i. e., by wise and judicious legislation, for, in the light of facts, who can truthfully argue it is nobody’s business whom we marry ? In conclusion, I might state that in the preparation of this paper, 1 am greatly indebted for much of its subject matter to the following authors : Clouston, Blandford, Spitzka, Shaw, Mann, Hammond, Hamilton, Gray, Maudesley and several others; besides cullings from the various periodicals devoted exclusively to psychology and more especially to the able article of Dr. Camuset, of France, published in the Alienist and Neurologist for Sept., ’93. If I have succeeded in calling your attention to a subject which demands the highest and best interests of the physician, as well as the people whom we serve, the object of this paper will have filled its mission. 9 V e n e t 11 s, Ex Typography Nicolai Beuilacqua:, u d lix. Cvm PRIVILE 81 I S. Who are these Doctors? When did they live? What did they discover? These questions will be answered in an early issue of the TRI-STATE MED16AL JOURNAL, only Medical Journal in America with a Department devoted to the HISTORY OF MEDICINE. Our Practical Articles are written by the ablest Physicians, Surgeons and Specialists. Now is the time to subscribe. Subscription Price: $1.00 per year, in advance. Address Keokuk, Iowa.