Mental Responsibility and the Diagnosis of Insanity in Criminal Cases
225 Art. IV.? :Author: Edward C. Mann, M.D. Superintendent Sunnyside Medical Retreat for Mental and Nervous Diseases.
At the present day medico-legal cases are becoming very frequent, in which it is necessary to ascertain as to the insanity of a person accused of a criminal act, in its relation to his civil capacity and responsibility for criminal actions, and also as to feigned or concealed insanity. It becomes, therefore, a very interesting question as to what test of insanity the law should recognise as a valid defence in criminal cases. This question, although one which it seems difficult to settle satisfactorily, and which judges, lawyers, and medical experts are constantly disputing, assumes every day greater interest and wider sig- nificance, owing to the increase of insanity in our country dis- proportionate to the increase of population, which has taken place during the past twenty years, and which will continue to take place. Without inserting dry statistics, it is sufficient to say that a comparison of the increase of population from 1850 to 1870, with the increase of the number of the insane during the same period, reveals an increase of insanity over that of popula- tion of about 12 per cent. In the foreign elements this is due to marked changes in the habit of living, the changes of food, increased intemperance, working more indoors, living in badly ventilated tenements, and disappointments in not succeeding in business, &c., as they had expected to do in America, which are causes that, all combined, impair health, break down the nervous system, and tend insensibly towards insanity in the offspring. The increase of insanity among our own population is due largely to a change from the vigorous, well-balanced organisation, to an undue predominance of the nervous tempera- ment, which is gradually taking place in successive generations. The educational pressure on the young to the neglect of physical exercise, the increasing artificial and unnatural habits of living, the great excitement and competition in business, are all tending to induce and multiply nervous diseases, many of which must terminate in insanity. These causes, and the evils resulting from them, are propagated by the laws of inheritance in an aggravated Head before the New York Medico-Legal Society.
and intensified form. Insanity is also appearing- gradually at an earlier age than formerly. In former years the average period at which the greatest number became insane, ranged between the ages of thirty and forty, but an analysis of statistics shows that this average age is coming on at an earlier period, generally appearing between the years of twenty and thirty. This is owing to hereditary influences, which have gradually become intensified by the violation of physical laws during early life, want of proper training, or too high pressure in education, and is also due largely to the great mental activity and strain upon the nervous system that appertain to the present age and state of civilisation, and which tend to a rapid decay of the nervous system. With many persons it is but a step from extreme nervous susceptibility to downright hysteria, and from that to covert insanity. The question of mental responsibility in its relation to criminal cases is one of great interest, and presents a wide field for study and investigation. The facts of criminal psychology have led the writer to regard the impulse of criminal natures in the light of natural laws, and there is, beyond all doubt, an anthropological change which lies at the foundation of criminal propensities. There is a deficient cerebral organisation which lies at the foundation of these criminal natures, which occasions the dis- position of an abnormal moral constitution. The dislike of work and the love of enjoyment are impulses which, when combined, lead especially to crime?when the ethic constitution or develop- ment is wanting which is necessary to the foundation of a power- ful feeling of what is right.
A further fundamental element, which stands in psycho- physical contrast to dislike of work, is an excessive physical consciousness of strength, which leads to arrogance, and thereby to the pleasure of measuring strength against the weak. This impulse leads to the love of bullying, cruelty, and murder, if the higher intellect is absent, which should turn the feeling of strength in a right direction, and there is also absent a complete ethical consciousness, which should prevent misuse of power. This ethical weakness may be congenital, as has been remarked, or it may arise from deficient education. In the domain of vices we meet with a peculiar condition of the central nervous system, which results in temporary criminal impulse returning with a certain regularity. Such criminals are temporarily seized with the deepest remorse, and are fortified Avith the best resolutions. Ihey behave for a time in the most exemplary manner until they relapse again, which relapse is unanimously attributed by them to an irresistible impulse. This state of moral epilepsy is of great significance in the psychology of crime, as a physio- ogist is led to institute a comparison between such cases and several states of disease, in which a peculiar type is observable, consisting in the fact that attacks of illness of more or less duration alternate with more or less long, and generally for a time preponderant, healthy intermissions. In a broad sense, one may designate all these pathological states as epileptiform, hence the term ” moral epilepsy” which has been adopted above. Leaving this interesting question of the psychology of crime, we would ask if the true basis for jurists to proceed upon is not the protection of the existence of normal persons against the ethically degenerate ? And the unnecessary degree of this protection is, most certainly, an essential measure for the severity of the punishment. The first trial of note where there was the question of insanity advanced, was in 1723, when the trial of Arnold for shooting at Lord Onslow occurred. Although it was shown that Arnold had been of weak understanding from his birth, and that he was doubtless insane, the jury brought in a verdict of guilty, and Arnold would have been executed had it not been for the intercession of Lord Onslow. The language of the charge to the jury in this case was in conformity to the rule laid down by Lord Hale, that partial insanity does not excuse a person from the consequence of his act, and that only a total depri- vation of reason can furnish such excuse. In the year 1800 the celebrated trial of Hatfield, for shooting at the king in Drury Lane Theatre, excited much interest. Although it was proved that in 1793 Hatfield, who was a dragoon, had received a num- ber of severe wounds which had caused partial insanity, so that he was dismissed from the service, and that since that time he had had periodic attacks of insanity, and had been confined as a lunatic, the prosecuting attorney laid down the established rule, that a total absence of memory and understanding could alone shield the prisoner from punishment, and appealed to the jury for a conviction on that ground. It was only through the brilliancy of the advocate (afterwards Lord Erskine) that the prisoner was acquitted. This trial had a good effect upon the judiciary, as in the year 1812, in the trial of Bellingham for the murder of Spencer Percival, Lord Mansfield laid down the law that the capability of distinguishing between right and wrong was the test for determining the prisoner’s responsibility, thus discarding the old theory of an entire absence of all mental power and substituting this in its place. Afterward the theory of a general knowledge between right and wrong was modified, and the element introduced that the prisoner must know the difference between right and wrong at the time of, and with regard to the particular act for which he is on trial, in order to render him re- sponsible, and this test has been preserved to the present time. In the early history of our own country, the same barbarism in the treatment of the insane prevailed which darkens the pages of English history. In Governor Winthrop’s History of New Eng- land, the case of Dorothy Dalbye is mentioned. She was exe- cuted for killing her child. She was, beyond all doubt, an insane woman, but this fact was not recognised by Governor Winthrop, who says of her: ” She was so possessed with Satan that he per- suaded her by his delusions, which she listened to as revelations from G-od, to break the neck of her own child, that she might free it from future misery.” Such was the ignorance and pre- judice of the early history of our country. We are at the present day very far from a correct understanding of the work- ings of the insane mind, for in the recent trial of Scannall the law was laid down as enunciated by the Court of Appeals in 1865, in the case of ” Willis v. The People,” which held that a person was not insane who knew right from wrong, and that the act he was committing was a violation, and wrong in itself. This theory of right and wrong is utterly inadequate to meet a large class of cases. There are certain cases familiar to all specialists in insanity which suffer from impulse in insanity with a homi- cidal or suicidal monomania. These patients, without appreciable disorder of the intellect, are impelled by a terrible vis a tergo, a morbid, uncontrollable impulse, to desperate acts of suicide or homicide. These patients are often fully aware of their morbid state, appreciate perfectly the nature of the act toward which they are impelled, and feel deeply the horror of their situation, and yet, if not prevented by restraint, will inevitably commit acts of suicide or homicide. A very remarkable case was under the care of the writer, of a man who would at stated times acknowledge that he felt an irresistible desire to kill some one, and would voluntarily enter an asylum and remain there until this morbid impulse had passed away, which was generally a period of one or two months. He has often told the writer that his life was made miserable by the idea that at some time this overwhelming impulse would come upon him so suddenly that he should commit some desperately homicidal act, but is not prepared to voluntarily incarcerate himself in an asylum for life, as his lucid intervals sometimes lasted for months at a time. The law as laid down at present would not decide this man to be insane, as he fully appreciates the difference between right and wrong, and the nature and consequences of any homicidal act that he may in the future commit. Such cases, which are not at all uncommon, serve to show what fearful injustice may be done under the name of justice, when the conclusion is based upon a metaphysical test which is proved by medical observa- tion to be false in its application to the unsound mind.
lhere is still another form of insanity denominated ” moral insanity,” in which the intellectual faculties are intact, no delu- sions or hallucinations existing, but where the moral sense seems utterly obliterated. Such persons have no true moral feeling This is disorder of the mind produced by disease of the brain, and is an unquestionable form of insanity, as it often precedes other forms of insanity, in which intellectual derangement is well marked, as acute mania or general paralysis. In some of these cases there is a modified responsibility, the degree of such responsibility being determined by the particular circumstances of each individual case. One difficult but important question to be solved is the civil and criminal responsibility of women who plead insanity before courts of justice, and who are often afflicted with kleptomania, pyromania, or who are infanticides, as a result of sexual trouble and disease of the pelvic organs. Such women under all reasonable conditions are entitled to the benefit of the doubt, because of their defective mental integrity, caused perhaps by pregnancy, or by the subsequent emotional excitement attending parturition, which intensifies the cerebral disorder in a brain already morbidly active. With women, extreme nervous susceptibility readily lapses into insanity. In the sexual evolution, in the parturient period, in lactation, strange thoughts, extraordinary feelings, unreasonable appetites, criminal and suicidal impulses, may haunt a mind at other times innocent and pure. It is probable also that young un- married women guilty of killing their own newborn offspring, are so distracted by conflicting feelings, sharpened to morbid acuteness by the great physiological movement of parturition, as to be hardly responsible for their acts. We come now to the question of the diagnosis of insanity. In most diseases we examine physical signs and symptoms, and determine by our senses the existence of such diseases. In insanity, on the con- trary, we have to be guided chiefly by our knowledge of the normal functions of the mind, and in an examination have to rely on our intellect, rather than on our senses; although, of course, the latter are called in to assist us. It is, however, very often extremely difficult to decide with certainty, as medical experts are expected to do, as to the existence of mental disease. In making an examination of a person accused of crime, and in whom insanity is suspected, the person should be visited by the medical examiner, who should draw him into a pleasant conversa- tion, and inquire as to previous attacks of insanity, hereditary history, then into any predisposing causes ot insanity, such as intemperance, vocation, habit, &c., which may have operated in the production of insanity. Also as to injuries of the head or spine which may have occurred, sunstroke, &c. The nervous system should then be examined for the existence of any such diseases as paralysis, epilepsy, catalepsy, or hysteria. The different senses, beginning with sight, should be examined, and in this way it may be discovered if there are hallucinations or illusions pertaining to any of the senses. A great many cases are on the border line which separates sanity from insanity, and it often requires the nicest discrimination to determine whether such a patient has passed this border line. The writer would suggest a series of eight questions, which, if adopted by jurists in criminal cases, would prove a most efficient and just test as to the existence of insanity in any given case, viz.:? 1. Have the prisoner’s volitions, impulses, or acts, been determined or influenced at all by insanity, and are his mental functions?thought, feeling, and action?so deranged, either together or separately, as to incapacitate him for the relations of life ?
2. Does the prisoner come of a stock whose nervous con- stitution has been vitiated by some defect or ailment calculated to impair its efficiency or derange its operations ? 3. Has the prisoner been noticed to display mental infirmi- ties or peculiarities which were due either to hereditary trans- mission or present mental derangement ?
4. Has the prisoner the ability to control mental action, or has he not sufficient mental power to control the sudden impulses of his disordered mind, and does he act under the blind influence of evil impulses which he can neither regulate nor control ?
5. Has the act been influenced at all by hereditary taint which has become intensified, so.that the morbid element has become quickened into overpowering activity, and so that the moral senses have been overborne by the superior force derived from disease ?
(j. Was the act effected by or the . product of insane delu- sion ? 7. “Was the act performed without adequate incentive or motive ?
8. Does the prisoner manifest excitement or depression, moody, difficult temper, extraordinary proneness to jealousy and suspicion, a habit of unseasonably disregarding ordinary ways, customs, and observances, an habitual extravagance of thought and feeling, an inability to appreciate nice moral distinctions, and finally, does he give way to gusts of passion and reckless indulgence of appetite ?
Some, or all of these are found generally in connection with transmitted mental infirmity. It may be argued that these mental defects signify not mental unsoundness, but human imperfection. Certainly if we take these manifestations, any one of them singly and alone, we cannot claim such a one as invariably an indication of insanity; but, on the other hand, under certain circumstances, each one of them may be an unmistakable sign of insanity, or rather of a morbid cerebral state, which may readily lapse into insanity. The disappoint- ments and calamities of life obviously act with greater effect upon an unstable mental organisation, these causes of disturb- ance meeting with a powerful co-operating cause in the constitutional predisposition. Sometimes a crime, even when there have been no previous symptoms to indicate disease, marks the period when an insane tendency has passed into actual insanity?when a weak organ has given way under the strain put upon it. There is a class of persons, with a peculiar, nervous temperament, who inhabit the border land between crime and insanity, one portion of which exhibit some insanity but more of vice, and the other portion of which exhibit some vice but a preponderance of insanity, and it is very difficult to form a just estimate of the moral responsibility of such persons, especially when we reflect upon the fact that moral feeling is a function of organisation, and is as essentially dependent upon the integrity of that part of the nervous system which ministers to its manifestations, as in any other display of mental func- tion. The writer has met with cases in which, as a result of parental insanity, there has been a seemingly complete absence of moral sense and feeling in the offspring, and this has been a true congenital deprivation, or a moral imbecility, so to speak ; of course such children can hardly fail to become criminals. In this connection it is interesting to note that moral degene- racy often follows as a sequence upon disease or injury to the brain. A severe attack of insanity sometimes produces the same effect, the intellectual faculties remaining as acute as ever, while the moral sense becomes obliterated.
When such persons are acquitted on trial of a criminal act on the ground of insanity, they should be remanded to medical custody, and should never be set at liberty until the medical superintendent of the asylum deems them fully reco- vered ; but the commonest justice plainly indicates that such custodial restraint be of a medical and not of a penal nature. It is a very difficult thing for the laity to realise how sane a person may appear who all the while has a greater derangement than was even suspected until something happens to elicit the evidence of it, such as an attack of illness or severe mental strain, and some unconquerable impulse seizes him, and some homicidal or suicidal act results to the great surprise of every- one. In the same manner inebriety often appears in maturity as a result of ill health, mental shock, &c., and it becomes an interesting question as to the degree of moral and criminal responsibility which attaches to inebriates, as inebriety often depends upon an abnormal organic development of the nervous system that has descended from generation to generation, gaining in intensity until it manifests itself in active inebriety; and there must certainly be a modified responsibility when homi- cidal or suicidal acts are committed during periods of such abnormal cerebration. In such cases a criminal act may be committed in consequence of cerebro-mental disease, without any apparent lesion of the perceptive and reasoning powers. In these cases also, the mental disorder is of a sudden and transitory character, not preceded by any symptoms calculated to excite suspicion of insanity. It is a transitory mania, or sudden paroxysm, without antecedent manifestation, the duration of the morbid state being short and the cessation sudden. In these cases the criminal acts are generally monstrous, unpre- meditated, motiveless, and entirely out of keeping with the previous character and habit of thought of the individual. Such attacks are transient in proportion to their violence, and transition occurs in the completion of the act of violence. There is an instantaneous abeyance of judgment and reason during which period the person is actuated by mad and uncon- querable impulses.
We will consider, finally, the medico-legal importance of epileptiform attacks, which may be partial in character, and which may not reach convulsive activity except so far as the mind is concerned. These attacks always display periodicity, and after the paroxysm there is an intermediate stage, during which, in most cases, the person remains in a confused state, perhaps for some hours, and is apt subsequently to retain only a vague and general notion of the preceding events. Thus in a homicide by shooting, the murderer would be likely to be roused by the sound of the pistol shot, and to remember it, although he would not very likely remember the altercation at all, or what passed between them. A case occurred recently of con- siderable interest from a medico-legal point of view, in which a murder was committed during an epileptiform seizure, or rather, more strictly speaking, during a state of transitory moral epilepsy, which was the result of a previous sunstroke, the im- mediate exciting cause being an attack of illness and the taking of a small quantity of alcoholic stimulus, which, it is well known, acts as a poison upon persons who have been sunstruck. This state of ” moral epilepsy” is a morbid affection of the mind centres, which destroys the healthy co-ordination of ideas, and occasions a spasmodic or convulsive mental action. 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. The case just referred to had complained of pains in the head and sleeplessness, which had displayed marked periodicity, and which had been accompanied with great irrita- bility of temper, excited by trifles and seemingly unconnected with personal antipathies. As has been previously stated, the person alluded to had been suffering from quite a severe illness, and after taking a small quantity of alcoholic stimulus went out to walk. He met a friend with whom he had been familiar for years, and a discussion arose as to the respective merits of cer- tain politicians, when the discussion becoming excited, the man pulled out a revolver and shot his friend. He then went in a confused and dazed state and sat for some hours on a dock near a river, and subsequently went home, and burst into tears, and informed his wife of the sad occurrence, and gave himself up at the police station. There was no simulation of insanity by pretending to be incoherent, or by strange actions,and no attempt, either on the part of himself or wife, to pretend that the act was an insane one. There was, however, a total blank in the prisoner’s mind respecting the events immediately preceding the pistol shot which seemed to have aroused his attention at the time, and he had no recollection of the fact that he had sat on the dock for some time afterward, as he was seen to do. The writer was consulted as an expert, and upon ascertaining the prisoner’s previous history, gave it as his opinion that there had existed for months previous to the occurrence a profound moral or affective derangement, which, from its marked periodicity, was evidently epileptiform in character, and that the sudden homi- cidal outburst supplied the interpretation of the previously obscure attacks of recurrent derangement. There had evidently been induced by the sunstroke in this case an epileptiform neurosis, which had been manifesting itself for months, chiefly by irritability, suspicion, moroseness, and perversion of character, with periodic exacerbations of excitement, all foreign to the man previous to the attack of sunstroke. It is well known among specialists in insanity that this epileptiform neurosis often exists for a long time in an undeveloped or marked form, and that this neurosis is, moreoyer, connected with both homicidal and suicidal mania. Such attacks are often noticed to occur periodically for some time before the access of genuine epilepsy. I have often witnessed, in cases under my charge, abortive or incom- plete epileptiform attacks, where there were no convulsions, and where there was no complete loss of consciousness. I have noticed in such cases either a momentary terror, slight incoherence, a gust of passion, or a mental blank, the patient perhaps stopping in the middle of a sentence. The patient would then be him- self again, quite unconscious of what had happened to him.
Accompanying this confusion of ideas may be, as I have remarked, instantaneous impulses, either of a suicidal or homicidal nature. Owing to the writings of Hughlings-Jackson, Maudslev, Russell Reynolds, Hammond, Trousseau, Falret, Esquirol, and others, epileptic vertigo is a recognised disease. There is abundant testimony to show that during such seizures persons may perform actions, and even speak and answer ques- tions, automatically. There are numerous examples in the works of the above authors, proving that in an unconscious condition persons can progress from odd or eccentric action to deeds of violence, suicide, or murder?being unable to remember the circumstances afterwards, and therefore irresponsible for their actions. This class of patients I have always found irritable, easily excited, very emotional without adequate external cause, easily losing their train of thought, and often unable to collect or fix their thoughts. Such cases have told me that they felt themselves changed in character, and have acknowledged that they often felt impelled to strange and violent acts by some power which they could neither understand nor resist. Such patients may entertain delusions of fear and persecution, and commit criminal deeds as a result of such delusions. When such cases, in their terror or distress of mind, commit some violent deed, they either experience immediate relief, as was the case with one patient under my care, who was only relieved by breaking out a pane of glass, when his paroxysm would subside, or they continued in a state of excitement, unconscious, or very imperfectly conscious, of the gravity of their acts. When they become conscious again, their memory is apt to be very uncertain as to preceding events, Griesinger says: ” Individuals hitherto perfectly 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.” Maudsley says: ” Let it be borne in mind, then, that there are latent tendencies 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 disorder, and that the outbreak of actual disease may then be the first positive symptom of unsoundness.” The question as to the degree of mental responsibility attaching to such cases is one of great interest to psychologists, and also to jurists, and one to which it is hoped, in the future, much more attention may be directed than has been given to it in the past.
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