Insanity in its medico-legal relations. / By A. C. Cowperthwait. / Title Contents

Title Contents


Page  I - Title Page

INSANITY IN ITS MEDICO-LEGAL RELATIONS. BY A.' OWPERTHWAIT, A. M., M. D. J. M. STODDART & CO. No. 723 CHESTNUT ST., 1876.

Page  II

Entered according to Act of Congress, in the year 1876, by A. C. COWPERTHWAIT, in the Office of the Librarian of Congress, at Washington.

Page  III - Table of Contents

CONTENTS. CHAPTER I. PAGE. I INTRODUCTION) CHAPTER II. PATHOLOGY, 6 CHAPTER III. CLASSIFICATION, CHAPTER IV. DIAGNOSIS, 29 CHAPTER V. CRIMINAL RESPONSIBILITY OF THE INSANE, CHAPTER VI. EPILEPTIC INSANITY, 0.. CHAPTER VII. TREATMENT OF THE INSANE, 0. 36 61 70 (iii)

Page  V

PREFACE. IN presenting these pages to the public, the author does not flatter himself by thinking that he is bringing forward any strikingly new or original ideas in regard to insanity; on the contrary, he has endeavored to incorporate, in as little space as possible, the ideas and observations of those who have already become eminent as alienist physicians, with a somewhat extended experience of his own, and thus to produce a work, which, while it may be very brief, will contain those essentia

Page  VI

vi Preface. thorough knowledge of the whole of mental pathology, and how greatly to be regretted, is the wide spread professional apathy and ignorance concerning it. In the language of a recent writer: " Were the vast array of incipient lunatics, who mingle unrecognized among our large population, to be suddenly discovered, the shock upon the community would be profound. Nevertheless, it would be wholesome. If the world clearly understood how much of the eccentricity and the moral perversit

Page  VII

Preface. vii for those who are unequivocally insane, but also for those, none the less unfortunate ones, who inhabit the borderland between mental health and mental disease, my object will have been fully attained. I desire to acknowledge my indebtedness to the following excellent works, which have assisted me in the prepar ation of these pages, and without which no physician's library is complete: "The Physiology and Pathology of the Mind," by H. Maudsley, M.D.; also " Responsibility in Me

Page  1

INSANITY. CHAPTER I. INTRODUCTION. The position of the medical man when called upon to testify in an obscure case of mental disease, though an unenviable one, is, nevertheless, one of the most important and honorable in which it is possible for him to be placed. Even in this enlightened day there are those who sneer at the idea of calling a physician to decide the question of insanity. A person in order to be insane, in their estimation, must either be a raging maniac, or, at least, be laboring

Page  2

Insanity.-Introduction. Then, as now, it must be the first duty of the medical man to uphold the truth against error, even though he thereby becomes a target for the rash and unjust censures of an ignorant multitude. "A wretch foredoomed to insanity by mal-organization or hereditary defed," observes Connolly, " or driven mad by poverty, or by disappointment a&ing on a distempered brain, has no other friends in the world. The same courage which causes the physician to brave the dangers of pest

Page  3

Insanity.-Introduction. 3 was one of faa to be determined by the jury on evidence. Experts may testify to the conditions of mental disease as they could not if such indications were matters of law." Judge Doe further observes that legal tests of responsibility have always been derived from medical authorities, who profess to have founded their opinions on the observation of fads. They are virtually the dida of medical men, of experts-conflicting and liable to grow obsolete; and, therefore,

Page  4

4 Insanity.-Introduction. court for information, that necessity is now fully obviated by the services of counsel and the testimony of experts. If courts, instead of charging the jury to acquit the prisoner, if they find he was unable to distinguish right from wrong, or knew not that he was committing an unlawful ad, etc., should merely dired them to acquit if they believe the criminal ad to have been the offspring of disease, it can scarcely be questioned that much disatissfadion would be a

Page  5

1 nsanity.-Introduction. 0 2. He should be entirely independent, not allowing himself to be too cordial with the counsel by whom he has been called and for whose purposes, it is expeced that his testimony will be of value. 3. He should never, from a dread of being thought ignorant of his profession, permit to be drawn from him a positive and unqualified reply, when a modest doubt would better express the extent of his knowledge; neither should he ever give an opinion without mature consider

Page  6

6 Pathology of Insanity. may be given; but it should be borne in mind that it is the whole evidence upon which an opinion is to be founded; and, if that evidence is contradictory or deficient, the witness will best consult his own reputation, and promote the ends of justice by candidly stating the fat. CHAPTER II. PATHOLOGY. Insanity, unquestionably arises from a morbid ation of the brain, and is only a symptom of disease of that organ. For this reason it is not a proper object for definiti

Page  7

Pathology of Insanity. 7 veloped energy of nerve cell; but whatever be the real nature of the mind, it is most certainly dependent for its every manifestation on the brain and nervous system. It is interesting to note the intimate physiological relationship existing between the brain and other portions of the nervous system, which indudively leads to the assumption that the latter plays no small part in the creation of cerebral manifestations, and that they hold within themselves, an import

Page  8

8 Pathology of Insanity. As we ascend in the mammalia, the hemispheres gradually enlarge backwards, and in the Ruminantia and Pachydermata slight traces of convolutions are found, which become more fully developed in the Carnivora, and complete in the apes and in man. The longer, more numerous and complicated are these convolutions, the greater will be the degree of intelligence, all other things being equal, and, as these cerebral developments gradually ascend, with a correspondingly gradu

Page  9

Pathology of Insanity. 9 specific function to perform in cerebral manifestations. It is only by the acceptation and application of these physiological fats that we may safely proceed to investigate the pathological conditions of mental force, and hold true ideas as to the relations existing between the mind and nervous system. What constitutes the mind, or the relations that it holds to the body, whether material or spiritual, can never be satisfatorily answered from a metaphysical rather t

Page  10

10 Pathology of Insanity. immaterial principle. Yet we find that in diseases of other organs, pathological changes are also often absent, though the presence of atual disease in these cases is not questioned. Because no pathological changes are found, is no sign that nerve element does not subserve mental funtion. We know comparatively nothing of the intimate constitution of nerve element, for the reason that it has so far baffled human investigation, yet, because we do not see the changes,

Page  11

Pathology of Insanity. 11 quirements to give an opinion, are those who are most certain of the invariable existence of organic change. It is known that when a morbid poison a&s with its greatest intensity, there are fewer traces of organic alteration of structure found, than when the disorder has been of a milder character; and so likewise, organic change of nerve element in insanity, appreciable by the means of investigation which we now possess, may justly be expeted, only when the degene

Page  12

12 Pathology of Insanity. sometimes approaching insiduously, at other times breaking out without any warning; its development presents nothing strikingly peculiar, as it merges into its most dangerous form; neither does its termination in death or resolution, either suddenly or gradually, present any remarkable features, different from the same in other diseases. Sometimes proceeding through successive stages to the end with increasing severity, or interrupted by intervals of a longer or sh

Page  13

Insanlty.- Ciassifica lion. 2 25 out by the individual, although his intellect and his emotions are strongly exerted against it. Thus a person who previously has not exhibited any very obvious symptoms of mental derangement-though a careful inquiry will invariably show that slight evidences of cerebral disease have been present for some days-instantaneously feels a morbid impulse to commit a murder or perpetrate some other criminal act, and is forced to yield, notwithstanding a

Page  14

26 Insanity.--Classification. pleases him, and especially is he inclined to wander from place to place, hoping for relief. He soon complains of fullness in the head; he becomes exceedingly morose and irritable, and his ideas seem strangely confused. His digestive functions become deranged; his kidneys do not adt properly; the circulation and nutrition are interfered with; he is not able to sleep at all; or, if he does catch a few moments sleep, it is filled with agitating dreams; illusions

Page  15

Insanity.-Classification. over the moral sentiments and a(ions, which are often immoral and shamefully indecent. The patient becomes eccentric and whimsical to an astonishing degree, and finally delusions of an endless variety, and of the most extravagant nature supervene, and rapidly succeed each other. Simultaneous with these symptoms, or following closely in their train, there commences an insiduously advancing paralysis. This is first noticed in the indistin&i articulation, from paralysis

Page  16

28 Insanity.- Classification. its victims mostly from the higher walks of life, confining itself almost exclusively to the male population, and scarcely ever occurring except between the ages of thirty and sixty. It seems to arise mostly from alcoholic or sexual excesses, or from severe and prolonged mental activity. Its duration is variable, lasting from a few months to three or four years, or even longer; but whether progressing fast or slow, it is ever downwards, and, in most cases, soon

Page  17

Insanity.-Diagnosis. 29 three more acute attacks of derangement, these resembled in character those that occur in early life rather than such as are usually met with in adults. Between this mild form of mental weakness at one end of the scale, and the extremest examples of dementia, in which mental power is almost obliterated, at the other end, there are met with in pra&ice, cases marking every shade of the gradation." Every sort of delusion may be present, and an endless variety of strange

Page  18

30 Insanity.-Diagnosis. it is often difficult to determine whether the morbid mental condition is the dire&Et result of a diseased brain, or whether it is but the natural result of the existing predisposition. Dissipation may result in a morbid, demoralized mental condition, manifesting itself through immoral conduct, obscene language, blunted feelings and degraded desires. Sadness and depression of the mind may be the natural result of natural causes. Family bereavement, business losses,

Page  19

Insanity.-Diagnosis. 31 told, and which may be all true. If, after so doing, the information of the family is not considered reliable, the physician should not hesitate to inquire prudently and cautiously of.the neighbors and acquaintances of the family, in order to become thoroughly satisfied as to the hereditary predisposition and previous attacks, which are two most important diagnostic points. The hereditary transmission of all forms of nervous disease, is an accepted fact, and though t

Page  20

Insanit'y. -Diagnosis. motor nerve centres, giving an entirely new train of symptoms. Several cases are recorded in which there was an alternation between epilepsy and insanity, or chorea and insanity, the one giving place to the other at more or less regular intervals. Violent paroxysms of neuralgia have subsided at the outburst of mania, and again returned as the latter passed away. These observations not only show the kinship existing between insanity and nervous diseases, but robs the for

Page  21

Insanity.--Diagnosis. 33 the sober man becomes disappointed, the prudent man rash and extravagant, the moral or religious man dissolute, the modest woman shamefully indecent, there can be little question of the presence of cerebral disease; yet, as previously remarked, search should be made for any predisposing causes that might operate in a natural way to produce these changes. They are but a lack of control over the affective and intelle&tual faculties, which are by nature depraved, and w

Page  22

34 Insanity.-Diagnosis. sume a quiet indifference, though it must be done in a natural manner, or the unfitting mask will at once excite the patient's suspicions. While, to all appearances indifferently conversing on the most foreign topics, the observing physician may study the physiognomy and gestures of the patient, and find in them much valuable aid; the eccentricity of dress, from mere disorder to total nudity, or absurd peculiarities of arrangement in shape or color, so often present,

Page  23

Insanity--Diagnosis. 35 quiry on these and similar subjects, he certainly cannot be the subject of mania; and if he has any delusions, he must either retain the power of hiding them, or they must exist in some obscure corner of the brain, from which they are little likely to influence, with any force, the opinions, the feelings, or the conduc."-Bucknill. It sometimes becomes necessary to distinguish between insanity and some other form of cerebral affection, which is usually a matter of but

Page  24

36 Insanity.- Criminal Responsibility of the Insane. he may adopt the hint. The history of the case, and especially of the mode of occurrence of the disease, and of the circumstance of its development, will most materially aid the diagnosis. If there be no previous history to be had, and if the patient refuse to converse, a long observation may be necessary to come to a decision. When a man feigns madness so perfe~tly as to deceive an experienced observer, we may hold, I think, that he is not f

Page  25

Insanity.-Criminal Responsibility of Insane. 37 of nervous communication unites in harmony man's whole being, and, while the fun~lions of the brain are specially connected with the mind, there is not an organ or tissue in the body that does not bear a direct influence upon that organ. Man, born with this higher principle of mind or soul, giving him intellea and reason, and placing him in the highest scale of animal creation, is destitute of many of those instinaive faculties which belong to th

Page  26

38 Insanity.-Criminal Responsibility of Insane. possessed of a mean defective intellect, they are true moral imbeciles. In proportion with this congenital weakness of the mind, do we find, also, a physical degeneration, which may manifest itself in congenital deformity, scrofula or neurosis, but which, in every case, leaves the impress of a low physical and mental capacity upon the physiognomy, constituting a family likeness by which they are distinctively marked off from the balance of manki

Page  27

Insanity.--Criminal Responsibility of Insane. 39 cerebral degeneracy until he passes the invisible line of transition, and is diseased. During this evolution, he occupies the border land between crime and insanity, " near one boundary of which," says Maudsley, " 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 responsibility of the unhappy people inhabiting this border land, will assure

Page  28

40 Insanity.-Criminal Responsibility of Insane. In fact, as we look back over the various and conflicting tests of responsibility that have been conceived and abandoned during the past century, we cannotbut admitthat they are all unreliable, and that a real and positive test of responsibility-one that may be relied upon in every case, will never be established. The only just test is " the inability to control the action of the mind," and properly speaking, this is no test at all, being only a

Page  29

Insanity.--Criminal Responsibility of Insane. 41 Lane Theatre, in which he said: "I am bound to admit that there is a wide distinction between civil and criminal cases. If in the former a man appears, upon the evidence, to be non compos inentis, the law avoids his act, though it cannot be traced or connected with the morbid imagination, which constitutes his disease, and which may be extremely partial in its influence upon conduct; but to deliver a man from responsibility for crimes, above all

Page  30

42 Insanity.--Criminal Responsibility of Insane. the mind commands them to sacrifice the lives of that family for some insane or delusive reason. As, for instance, the case reported by Mittermaier, when he enquired of a man in an asylum, who had killed his father, if he did not know that parricide is a crime severely punished. "I know it very well," he replied, "but God having sent me into the world to punish great sinners, of whom my father was one, I killed him according to the divine comma

Page  31

Insanity.-Criminal Responsibility of Insane. 43 The individual may know the act to be contrary to law and yet think the peculiar circumstances justify him in disregarding the law. He may think it is legally as well as morally right to revenge some supposed defamation of character, or injury to fortune, by taking the life of the supposed enemy. After the acquittal of McNaughton for the murder of Drummond, in 1843, on the plea of insanity, the House of Lords, evidently sympathizing with an ignor

Page  32

44 Insaniiy.-Crimina/ Responsihility of Insane. that were injuring his character, and destroying his peace, which, had such been real, would not have justified the crime of murder; Lord Denman, also, approved the acquittal of Oxford, who shot at the Queen because he supposed that killing the Queen was necessary in order to accomplish a certain great benefit to the public. " Such a remarkable doctrine as this," observed Ray, "can have sprung only from the most deplorable ignorance of the menta

Page  33

Insanity.-Criminal Responsibility of Insane. 45 In the case of State v. Jones, tried in the New Hampshire courts, judge Ladd commented upon this doctrine of the English, judges as follows:' "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 problem since that day. Yet it is probable that no ingenious student of the law has ever read it for the first time without being shocked by its exquisite

Page  34

46 Insanity.-Criminal Responsibility of Insane. 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.... 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 rea

Page  35

Insanity.-Criminal Responsibility of Insane. 47 shire) " if the killing was the offspring of mental disease in the defendant; that neither delusion or knowledge of right and wrong, nor design or cunning in planning and,executing the killing, and in escaping or avoiding detection, nor ability to recognize acquaintance, or to labor., or to 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 matter

Page  36

48 Insanity.- Criminal Responsibility of Insane. dloctors in the medical profession, that if the man has the least taint of insanity entering into his mental structure, it discharges him from all responsibility to law. This is a monstrous doctrine, to which may be traced the fruitfulness ofcrime, and the immunity which have attended them in different parts of our country..........Did the accused act in the matter from thought and design, and understand right from wrong? Did he, by seeking co

Page  37

Insanity.- Criminal Responsibility of Insane. 49 ist, or if existing, it is not inuch manifest, and has not to all external appearances influenced the act, then it is held that he should be responsible. Even further does socalled justice go; for, if the person has a most frightful delusion, but it cannot be known that the crime is a direct result of that delusion, then he must be responsible. With a delusion to prove in general a diseased mind, who can say there are not other delusions reignin

Page  38

50 Insanity.-Criminal Responsibility of Insane. not the disease," says Maudsley, " it is only the striking symptom of the disease, and it is certain that the criminal act may be the manifestation of the disease of which the delusion is a symptom, and that no connection between them may be detected by the looker-on, notwithstanding the existence of a real pathological condition." The courts of justice should not strive to trace a connection between the delusion and the crime, both of which ar

Page  39

Insanity.- Criminal Responsibility of Insane. 51 person can for a long time simulate sanity, when it is to their interest to do so, there can be no doubt, and this fact is used as an argument that the same strength of will by which he thus controls his insane actions should make him fully responsible for the act which he so cunningly plans and consummates, knowing it all the time to be a crime. It must be realized that this is all the result of a diseased brain, and that it is not the individu

Page  40

52 Insanity.- Criminal Responsibility of Insane. wrong in the particular instance-should contrive the means of murder, do it deliberately, and endeavor to escape the consequences afterwards.' '-Maudsley. Wharton & Stille relate the following case, which is a striking example of the cool and daring cunning of insanity, and of the sense of responsibility that may accompany it: "'A man named John Billman, who had been sent to the Eastern Penitentiary of Pennsylvania for horse-stealing, murdered

Page  41

]nsniy.CrmialReponsibility of Insane. 53 under circumstances which he detailed with great minuteness and zest. Inquiries 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 the wvindow. Here was

Page  42

54 Insanity.- Criminal Responsibility of Insane. impulsive character of its paroxysms, becomes a most dangerous form of mental disease. It consists in an insane impulse, acting upon a diseased mind, and which the latter has not the power to resist. This impulse is usually either of a suicidal or homicidal nature;. but it is those cases in which develop the latter form, that most frequently demand the attention of the expert. It is surprising, how long a person possessed of a neurotic temperam