Text-book of forensic medicine and toxicology

Chapter XVI: Mental Unsoundness (1)

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In the whole range of medical jurisprudence there is no subject more interesting, more difficult, or more important than the diagnosis of insanity, and its relation to the criminal responsibility of individuals. It is impossible, in the short space at our disposal, to do more than to offer a few remarks which may assist the student in the elucidation of some of the most important cases which may engage his attention.

=Legal Definitions.=--Three forms of mental disorder are recognised in law:

1. _A nativitate, vel dementia naturalis_--idiocy or imbecility.

2. _Dementia accidentalis, vel adventitia_--acquired general
insanity, either temporary or permanent, lunacy.

3. _Dementia affectata_, acquired madness from intoxication, &c.
(See “Delirium Tremens,” p. 205.)

Under the term lunacy are included the mania, monomania, and dementia of medical writers. Another term frequently used in legal proceedings, the meaning of which it is not easy to give, is “_non compos mentis_,” _unsoundness of mind_. According to the late Forbes Winslow, “unsoundness of mind is not lunacy” in the legal acceptance of the phrase. This term was first used in a Statute passed in the reign of Henry VIII., relating to the punishment of treasonable offences, and is defined by the early law text-books to be strictly one who _gaudet lucidis intervallis_--a definition not psychologically exact. The phrase “unsoundness of mind” was first used by the late Lord Eldon to designate a state of mind not exactly idiotic, and not lunatic with delusions, but a condition of intellect occupying a place between the two extremes, and unfitting the person for the government of himself and the management of his affairs.

The above definition has been acted upon by other judges--Lyndhurst, Brougham, &c. As a rule, a medical witness will consult his own interest in not attempting to define insanity, bearing in mind the philosophic caution of Polonius, who, when addressing Hamlet‘s mother, says--

“Your noble son is mad: Mad call I it; for, to define true madness, What is‘t but to be nothing else but mad?” To the legal mind, the chief character of insanity is the presence of _delusion_; but this view is far too restricted. It was first advanced by Erskine in the trial of Hadfield. Before that trial the doctrine was that every man was responsible for his acts, unless he was totally deprived of his understanding and memory, and did not know what he was doing, “no more than an infant, than a brute, or a wild beast” (R. _v._ Arnold). In the case of Bellingham, the knowledge of “right” and “wrong” in the abstract was the test of mental unsoundness; and, as in the opinion of the judge and jury he was held to be capable of solving this metaphysical problem, Bellingham was duly hanged.

Since the trial and acquittal of MacNaughton on the ground of insanity, the doctrine of the knowledge of abstract right and wrong has been changed to a knowledge of right and wrong in relation to the particular act of which the person is accused, and also at the time of committing it.

It has also been held that, on the assumption that a person labours under partial delusion only, and is not in other respects insane, he must be considered in the same situation as to responsibility as if the facts, with respect to which the delusion exists, were real. For example, if, under the influence of delusion, he supposes another man to be in the act of attempting to take his life, and he kills that man, as he supposes, in self-defence, he would be exempt from punishment. If his delusion were that the deceased had inflicted a serious injury on his character and fortune, and he killed him in revenge for such supposed injury, he would be liable to punishment. “Here,” says Maudsley, “is an unhesitating assumption that a man, having an insane delusion, has the power to think and act in regard to it _reasonably_, ... that he is, in fact, bound to be reasonable in his unreason, sane in his insanity.” Yet this was the doctrine laid down by the judges in answer to certain questions propounded by the House of Lords after the acquittal of MacNaughton (see Maudsley‘s _Responsibility in Mental Disease_, pp. 88 _et seq._).

As laid down by English lawyers, madness absolves from all guilt in criminal cases. Where the deprivation of the understanding and memory is total, fixed, and permanent, it excuses all acts; so, likewise, a man labouring under adventitious insanity is, during the frenzy, entitled to the same indulgence, in the same degree, as one whose disorder is fixed and permanent (Beverley‘s Case, Co. 125, Co. Litt. 247, 1 Hale 31). “But the difficulty in these cases is to distinguish between a total aberration of intellect and a partial or temporary delusion merely, notwithstanding which the patient may be capable of discerning right from wrong; in which case he will be guilty in the eye of the law, and amenable to punishment.”[17]

[17] Archbold‘s _Criminal Cases_.

Lord Hale, who first pointed out the distinction to be drawn between total and partial insanity, offered the following as the best test he could suggest: “Such a person, as labouring under melancholy distempers, hath yet as great understanding as ordinarily a child of fourteen years hath, is such a person as can be guilty of felony.” (On this subject, see R. _v_. Ld. Ferrers, 19 St. Tr. 333; R. _v_. Arnold, 16 St. Tr. 764, &c.)

To excuse a man from punishment on the ground of insanity, it appears that it must be distinctly proved that he was not capable of distinguishing right from wrong, and that he did not know, at the time of committing the crime, that the offence was against the laws of _God_ and _nature_ (R. _v_. Offord, 5 C. & P. 186).

I shall here quote from Macdonald‘s _Criminal Law of Scotland_: “Insanity or idiocy exempts from prosecution. But there must be an alienation of reason such as misleads the judgment, so that the person does not know ‘the nature of the quality of the act’ he is doing, or if he does know it, that he does not know he is doing what is wrong. If there be this alienation, as connected with the act committed, he is not liable to punishment, though his conduct may be otherwise rational. For example, if he kill another when under an insane delusion as to the conduct and character of the person--_e.g._ believing that he is about to murder him, or is an evil spirit,--then it matters not that he has a general notion of right and wrong. For, in such a case, ‘as well might he be utterly ignorant of the quality of murder.’ He does the deed, knowing murder to be wrong, but his delusion makes him believe he is acting in self-defence, or against a spirit. Nor does it alter the effect of the fact of insanity at the time, that the person afterwards recovers.... But the alienation of reason must be substantial. Oddness or eccentricity, however marked, or even weakness of mind, will not avail as a defence. Even monomania may be insufficient as a defence, where the delusion and the crime committed have no connection, or where the person, though having delusions, was yet aware that what he did was illegal.”

Mere moral insanity--where the intellectual faculties are sound, and the person knows what he is doing, and that he is doing wrong, but has no control over himself, and acts under an uncontrollable impulse--does not render him irresponsible (R. _v_. Burton, 3 F. & F. 772). Some medical writers contend that there are two forms of insanity--moral and intellectual. The law only recognises the latter, owing probably to the difficulty of distinguishing between so-called moral insanity and moral depravity. Taylor says: “Further, until medical men can produce a clear and well-defined distinction between moral depravity and moral insanity, such a doctrine, employed as it has been for the exculpation of persons charged with crime, should be rejected as inadmissible.”

The day may not be far distant when the term “moral depravity” will be unknown, and future generations, ceasing to believe in absurd superstitions, will come to look on crime as the result of disease of the brain, and learn to treat, instead of to punish, the morally diseased. (For a full discussion of this subject the reader is referred to the works of Dr. Henry Maudsley.)

The fact of the sanity or insanity of the prisoner at the time the crime was committed is left to the jury to decide, guided by the previous and contemporaneous acts of the party; and it has been laid down by Lord Moncreiff in Scotland, and Lord Westbury in England, that the mental soundness or unsoundness of any individual is to be decided by the jury on the ordinary rules of every-day life, and that on these principles they are as good judges as medical men. The whole tendency of legal practice, when dealing with the plea of insanity, is to entirely ignore the medical evidence. On the question of medical evidence in cases of insanity, Doe J., of New Hampshire, remarks: “At present, precedents require the jury to be instructed by experts in new medical theories, and by judges in old medical theories,” and that in this “the legal profession were invading the province of medicine, and attempting to install old exploded medical theories in the place of facts established in the progress of scientific knowledge. If the tests of insanity are matters of law, the practice of allowing experts to testify what they are should be discontinued; if they are matters of fact, the judge should no longer testify without being sworn as a witness, and showing himself qualified to testify as an expert.”

=Lunacy--What Constitutes?= (8 and 9 Vict. c. 100, secs. 90 and 114).--Imbecility and loss of mental power, whether arising from natural decay, or from paralysis, softening of the brain, or other natural cause, and although unaccompanied with frenzy or delusion of any kind, constitute unsoundness of mind, amounting to lunacy within the meaning of 8 and 9 Vict. c. 100 (R. _v_. Shaw, 1 C.C. 145).

The above is the last definition of lunacy up to 1875; but as the law on this subject is so constantly changing, the student will find it best to consult the _Law Reports_ from time to time. (See the account in the case of R. _v_. Treadaway, _Law Reports_. Also the _Lancet_, on the same case, vol. i. 1877.)

For some valuable remarks on the subject of the irresponsibility of madmen, the student is referred to the works of Maudsley, Pritchard, Ray, Hoffbauer, Georget, and others.

The following suggestions are offered for consideration on this subject:

1. Was the act an isolated event in the life of the culprit? Has it the appearance of spontaneity, or was it the culminating point of a life spent in so-called criminal acts?

2. _Absence of a motive for the committal of the deed._--The absence of an _apparent_ motive is no proof of an unsound mind; the moving principle may be _“the conscious impulse to the illegal gratification of a selfish desire_.”

3. _The presence or absence of a well-concerted plan of action is a diagnostic sign of little value._--Casper remarks that “only in one case can the examination of the systematic planning of the deed afford any information, and that is when these plans and preparations themselves evince the stamp of a confused intellect, and betray the hazy consciousness, the mental darkness, in which the culprit was involved.”

4. _A dominant delusion may be so concealed as to be for a time undiscoverable._--The case of the man who gave no indication of his madness till he was asked to sign the order for his release, when he signed _Christ_, is an example how carefully a delusion may be concealed even during a most careful examination. Questions directed to this point showed that he laboured under all the errors which such a delusion might suggest.

5. It may “easily be conceived that insane persons, whose unreason affects only one train of thought more or less restricted, yet labour in other respects under disorders of feeling which influence their conduct and their actions and behaviour without materially affecting their judgment: and that many of such deranged persons, who often conduct themselves tolerably well in a lunatic asylum, and while living among strangers with whom they have no relations, and against whom they have no prejudices or imaginary reason of complaint; subjected, besides, to the rules of the house and to an authority that nobody attempts to dispute; would, nevertheless, if restored to liberty and residing in the midst of their families, become insupportable, irritable at the slightest contradiction, abusive, impatient of the least remark on their conduct, and liable to be provoked by trifles to the most dangerous acts of violence. If, under such circumstances, a lunatic should commit any act of injury or serious damage to another, would it be just to punish him; because it cannot be made apparent that the action has any reference to, or connection with, the principal delusion which is known to cloud his judgment, it being apparent that his moral faculties have undergone a total morbid perversion?”

6. _Insanity with Lucid Intervals._--Haslam, Ray, and others appear to deny the possibility of lucid intervals; but M. Esquirol, on the other hand, fully recognises the existence of this form of insanity. In a legal sense, a temporary cessation of the insanity constitutes a lucid interval, but the cessation must be complete, and not merely a remission of the symptoms. The interval must be of some duration; and when continuous insanity has been proved, the onus of proving a lucid interval in civil cases rests with the party trying to support the validity of a deed executed during the alleged interval. “If you can establish,” says Sir W. Wynne, “that the party afflicted habitually by a malady of the mind has intermissions, and if there was an intermission of the disorder at the time of the act, that being proved is sufficient, and the general habitual insanity will not affect it, but the effect of it is this--it inverts the order of proof and presumption; for, until proof of habitual insanity, the presumption is that the party agent, like all human creatures, was rational; but when an habitual insanity in the mind of the person who does the act is established, then the party who would take advantage of the fact of an interval of reason must prove it.” In civil cases the law recognises the validity of wills made during lucid intervals, and has even taken the reasonableness of a will as a proof of a lucid interval.

7. Have measures been taken by the culprit to escape punishment?

The classification of insanity adopted here is that given by Ray, and is sufficient for all practical purposes:

{ 1. Resulting from
{ congenital defect.
{ 2. Resulting from an
{ obstacle to the
{ Defective { _Idiocy_ { development of the
{ development { { faculties supervening
{ of the { { in infancy.
{ faculties. {
{ { { 1. Resulting from
{ { { congenital defect.
{ { { 2. Resulting from an
{ { _Imbecility_ { obstacle to the
{ { { development of the
{ { { faculties supervening
{ { { in infancy.
INSANITY. {
{ Lesion of { { 1. Intellectual--
{ the faculties { { (_a_) General.
{ subsequent { _Mania_ { (_b_) Partial.
{ to their { { 2. Affective--
{ development. { { (_a_) General.
{ { { (_b_) Partial.
{ {
{ { { 1. Consecutive to mania,
{ { { or injuries of
{ { _Dementia_ { the brain.
{ { { 2. Senile, peculiar to
{ { { old age.

DEFECTIVE DEVELOPMENT OF THE FACULTIES

Under this heading may be included idiocy, cretinism, imbecility, feeble-mindedness, and moral imbecility.

=Idiocy= is congenital, and was defined by Esquirol thus: Idiocy is not a disease, but a condition in which the intellectual faculties are never manifested, or have never been developed sufficiently to enable the idiot to acquire such an amount of knowledge as persons of his own age, and placed in similar circumstances with himself, are capable of receiving. Idiocy commences with life, or at an age which precedes the development of the intellectual and affective faculties, which are from the first what they are doomed to be during the whole period of existence. Since the days of Esquirol, much improvement has been made in the care and treatment of the idiot; and it appears that he is capable of some, though in most cases slight, mental culture. The cases in which improvement takes place probably belong to imbecility, leaving the _idiot_ in the same condition as described by Esquirol.

=Cretinism= differs from idiocy in being endemic; it is also more curable, or at least more susceptible of improvement, than the latter. In the idiot the malady is congenital; the cretin, on the other hand, may to all appearances be free from disease for a time. “Every cretin is an idiot, but every idiot is not a cretin; idiocy is the more comprehensive term, cretinism is a special kind of it.” The enlarged thyroid gland, high-arched palate, and brown or yellow colour of the skin, are characteristic of the cretin. Local causes are at work in the production of cretinism; _e.g._ defective function of the thyroid gland.

The idiot is usually cunning, mischievous, and dirty in his habits.

The derivation of the word idiot, from the Greek, ἰδιώτης --_a private person_, or _an ill-informed ordinary fellow_--is peculiar. A person suffering from any form of mental unsoundness, and thereby rendered incapable of taking care of himself or of his property, was formerly called by English law “an idiot,” and this word was not infrequently joined with “fatuus” in old writs.

=Imbecility.=--This is a minor form of idiocy, and may or may not be congenital. It admits of considerable degrees of intensity. Imbeciles exhibit mental defection, rendering them incapable of managing themselves or their affairs, and imbecile children are incapable of being taught to do so.

=Feeble-mindedness= is a lesser degree of mental defection than imbecility. It may exist from birth or an early age. Such persons require care and control for the protection of themselves and others. They may be incapacitated from acquiring the knowledge imparted in ordinary schools.

=Moral imbeciles= exhibit moral defects which render them vicious in behaviour, and they often exhibit criminal tendencies, which are not affected by punishment.

CARE OF MENTALLY DEFECTIVE PERSONS

The Mental Deficiency Act of 1913 provides for their care. Such a person may be either sent to an institution or placed under special guardianship by the parent or guardian, if an idiot or imbecile; or by the parent when, though not an idiot or imbecile, the person affected be under the age of twenty-one years. If in addition to being a defective, the person is neglected, abandoned, or without means of support; or cruelly treated, guilty of a criminal offence, or liable to be sent to an industrial school, or under imprisonment, detained in an industrial school, inebriate reformatory, or institution for lunatics, or habitual drunkard within the meaning of the Inebriates Act; or in whose case proper notice has been given by the Local Education Authority; or who is in receipt of relief at the time of giving birth to an illegitimate child, or pregnant of such child.

=Certificates required.=--In the case of a parent or guardian who desires to place a mentally defective person under guardianship, _two medical certificates_ are necessary, one of which must be from a medical man approved by the Local Authority or Board. If the person be not an idiot or imbecile, the certificates must be signed by a Judicial Authority, after such inquiry as he thinks fit. A defective to be dealt with otherwise than by parent or guardian, is so under an order by a _Judicial Authority_ on a petition presented under the Act, an order of a _Court_ if guilty of a criminal offence, or an order of the Secretary of State if detained in prison, a criminal lunatic asylum, or reformatory.

The order of a Judicial Authority may be obtained by petition of any relative or friend, or an officer of the Local Authority authorised under the Act for the purpose. Two medical certificates must accompany the petitions, one of which must be signed by a medical man approved by the Local Authority or Board; or, when a medical examination cannot be carried out, a certificate to that effect must be presented, and a statutory declaration made by the petitioner and one other person, who may be one of the medical certifiers, stating the class to which the defective belongs. Upon receiving the certificates the Judicial Authority interviews the defective. When the petition is presented by a parent or guardian, the Judicial Authority, if satisfied, may issue an order for the defective to be placed in an institution or appoint a guardian. If the petitioner be not parent or guardian, consent in writing of one or other must be obtained, without which the order must not be made, unless the parent or guardian withhold their consent unreasonably or are not to be found. If the Judicial Authority be not satisfied, he may postpone the order, or refuse it.

When the order is made by a Court, the Court must be satisfied, on medical evidence, that the person is a defective.

Two medical certificates are necessary when the Secretary of State makes an order.

The order remains in force for a year, may be renewed for a second year, and then for periods of five years.

GENERAL SYMPTOMS OF INSANITY

The onset of insanity may be gradual or sudden. More commonly the onset is gradual, and manifested by alterations of emotion and conduct, which may for a considerable period precede any impairment of intelligence. Periods of depression may alternate with periods of excitement. Irritability and instability of temper manifest themselves, and lead relatives and friends to become suspicious of the change that is the herald of serious mental impairment. Lack of interest in environment, business, or the usual pleasurable pursuits, also a tendency to personal seclusion manifest themselves, and changeability of the affections, more often to those nearly related, are not uncommon. Sooner or later the capacity to conduct business and allied pursuits becomes enfeebled, and the power of judgment lessened; depression begets apprehension and a dread of impending ruin in this world or in the world to come. Marked indecision and vacillation of action is quite common. Delusions follow, mostly of persecution, in the form of attempts to cause ruin or poisoning. Delusions associated with the special senses are common, particularly of hearing, supposed voices urging the committal of certain actions, or expressive of derision; of vision, by which objects are seen which are non-existent; of taste, imparting the idea of poisoning; of touch and pain, invoking peculiar sensations; of smell, conveying the idea that food, the body, &c., exhale disgusting odours.

Associated with the onset of insanity, and remaining permanently, are three special distortions of perceptions--viz. _illusions_, _hallucinations_, and _delusions_. So long as the first two can be reasoned upon and rejected, judgment remains. At one or other time the afflicted person becomes so affected by them that they become realities, and are accepted as true and existent; then the judgment is perverted, and the person is said to suffer from a delusion.

_Illusions._--An illusion is a false perception, a perversion of the senses, a mockery, false show, counterfeit appearance. The false perception is, however, invoked by some external appearance.

_Hallucinations._--Hallucinations are perverted sensations and perceptions, for the production of which no external impulse is present. The person may complain of seeing horrible reptiles around, which are not present. So long as the reasoning faculties are capable of dispelling the alleged reality of the hallucination and rejecting it, it remains but an hallucination.

If, however, it becomes accepted as a reality and the person becomes obsessed thereby, it becomes a delusion.

_Delusions._--A delusion is a chimerical thought, an affection of the mind. It implies a disordered intellect. Delusions generally concern the insane person, his power, soul, &c. A delusion is a perverted idea of the mind in which there is belief in non-existent things or occurrences. Delusions may be based upon previous hallucinations, or arise out of erroneous conceptions.

MANIA

=Mania= is the result of a morbid condition of the brain, and to express which “the term raving madness may be used with propriety, as an English synonym for mania. All maniacs display this symptom occasionally, if not constantly, and in greater or less degree.” Like other diseases, mania observes the same pathological laws. There is a period of incubation, during which the true state of the patient is in most cases misunderstood, or not appreciated. Mental exaltation may exist from the first onset of the disease, or the attack may be ushered in by a stage of gloom or despondency. The general health shows signs of impairment, the liver becoming sluggish, and the bowels confined or relaxed. In some cases a febrile condition of the system is among the premonitory symptoms of an attack of mania. The physical health is not usually much affected during the paroxysm.

Dr. Conolly remarks that “even acute mania is not always accompanied by the ordinary external signs of excitement. It would seem as if we had yet to learn the real symptoms of cerebral irritation. Certainly, in recent cases of mania--cases which have lasted more than six weeks, and in young persons in whom I have seen the maniacal attack pass into dementia--I have known the most acute paroxysms of mania exist, rapid and violent talking, continual motion, inability to recognise surrounding persons and objects, a disposition to tear and destroy clothes and bedding, without any heat of the scalp or of the surface, without either flushing or paleness of the face, with a clean and natural appearance of the tongue, and a pulse no more than eighty or eighty-five.”

This may occur in some cases, but in the majority there is always some amount of physical derangement; the system, however, gradually becoming tolerant of the undue excitement to which it is subjected.

Following the classification adopted, Intellectual Mania will now be briefly considered under its two divisions--_General_ and _Partial_.

=General Intellectual Mania.=--By many medical writers general intellectual mania is divided into mania and melancholia. The mind in the former type of the disease is involved in the most chaotic confusion possible, and there is also considerable bodily derangement. The moral faculties become more or less affected, and the patient‘s social and domestic relations are greatly altered. At one time he is subject to violent fits of immoderate laughter, at another he is gloomy and taciturn; sometimes quiet and tractable, at others wild and excited, necessitating close confinement. He is haunted by wild delusions, which at times take entire possession of him, and under the influence of which he acts in the most extraordinary manner. In the latter--melancholia, or mania with depression--delusion may be absent, or, rather, for a time undetectable. The sufferer is gloomy, and troubled with unhappy thoughts, which sometimes lead him to self-destruction. He is sleepless, and rejects his food as unnecessary. He may be aroused for a short time by questions addressed to him, his replies to which are usually given correctly, most frequently in monosyllables; but the moment his questioner leaves him he relapses into his former gloomy state.

=Partial Intellectual Mania.=--The term _monomania_, first suggested by Esquirol, is now generally given to this variety of insanity. The patient, in the simplest form of this disorder, becomes possessed of some single notion, which is alike contradictory to common sense and to his own experience. Thus, he may fancy himself made of glass; and influenced by this idea, he walks with care, and in dread of being broken by contact with other bodies. In the case of an inmate at the City of London Asylum, the presence of a weasel in the stomach was stated by one woman. Esquirol mentions the case of a woman with hydatids in her womb, who believed that she was pregnant with the devil. Most of these strange fancies appear to be dependent on errors of sensation.

Monomaniacs are ready enough to declare their predominant idea; yet at times, and that without the occurrence of a lucid interval, they will as carefully conceal it. “In the simplest form of monomania, the understanding appears to be, and probably is, perfectly sound on all subjects but those connected with the hallucination. When, however, the disorder is more complicated, involving a longer train of morbid ideas, we have the high authority of Georget for believing that, though the patient may reason on many subjects unconnected with the particular illusion on which the insanity turns, the understanding is more extensively deranged than is generally suspected.”

MORAL MANIA

Pinel first drew attention to this form of madness. Pritchard defines it as “consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, and moral dispositions, without any notable lesion of the intellect or knowing and reasoning faculties, and particularly without any maniacal hallucinations.”

It is divided into--_General_ Moral Mania. _Partial_ Moral Mania.

=General Moral Mania.=--“There are many individuals,” says Pritchard, “living at large, and not entirely separated from society, who are affected in a certain degree with this modification of insanity. They are reputed persons of a singular, wayward, and eccentric character. An attentive observer will often recognise something remarkable in their manners and habits, which may lead him to entertain doubts as to their entire sanity; while circumstances are sometimes discovered on inquiry which add strength to this suspicion. In many instances it has been found that a hereditary tendency to madness has existed in the family, or that several relatives of the person affected have laboured under other diseases of the brain. The individual himself has been discovered to have suffered, in a former period of life, an attack of madness of a decided character. His temper and disposition are found to have undergone a change, or to be not what they were previously to a certain time; he has become an altered man, and the difference has perhaps been noted from the period when he sustained some reverse of fortune which deeply affected him, or the loss of some beloved relative. In other instances, an alteration in the character of the individual has ensued immediately on some severe shock which his bodily constitution has undergone. This has been either a disorder affecting the head, a slight attack of paralysis, or some febrile or inflammatory complaint, which has produced a perceptible change in the habitual state of his constitution. In some cases, the alteration in temper and habits has been gradual and imperceptible; and it seems only to have consisted in an exaltation and increase of peculiarities which were always more or less natural and habitual. Persons labouring under this disorder are capable of reasoning, or supporting an argument upon any subject within their sphere of knowledge that may be presented to them; and they often display great ingenuity in giving reasons for the eccentricities of their conduct, and in accounting for, and justifying, the state of moral feeling under which they appear to exist. In one sense, indeed, their intellectual faculties may be termed unsound--they think and act under the influence of strongly excited feelings; and persons accounted sane are, under such circumstances, proverbially liable to error, both in judgment and conduct.” (For interesting cases of this form of madness, see Ray‘s _Jurisprudence of Insanity_.)

=Partial Moral Mania.=--In the case of the unfortunate sufferers from this malady, one or two only of the moral powers are perverted.

This division admits of several subdivisions:--

_Kleptomania._--A marked propensity to theft. “There are persons,” says Rush, “who are moral to the highest degree as to certain duties, but who, nevertheless, lie under the influence of some vice. In one instance, a woman was exemplary in her obedience to every command of the moral law except one--she could not refrain from stealing. What made this vice more remarkable was, that she was in easy circumstances, and not addicted to extravagance in anything. Such was the propensity to this vice that, when she could lay her hands on nothing more valuable, she would often, at the table of a friend, fill her pockets secretly with bread. She both confessed and lamented her crime.”

_Pyromania._--This consists in an insane impulse to set fire to everything--houses, churches, and property of every kind and description.

_Erotomania and Nymphomania._--This is known as amorous madness, and consists in an inordinate and uncontrollable desire for sexual intercourse. The unfortunate victims of this disease often express the greatest disgust and repugnance for their conduct.

_Homicidal Mania_--In this form of madness the propensity to homicide is very great, and in most cases uncontrollable. In the case of the notorious Deeming, hanged in Australia in 1892 for the murder of his wife, an appeal was made from the finding of the Colonial Court by which he was tried to the Privy Council, on the ground of his being affected with homicidal mania. The plea was not sustained. (See the case of Henrietta Cornier, given by Pritchard, Ray, and others.)

The following suggestions may be of assistance in forming a diagnosis as to the existence or non-existence of this form of madness:--

1. Previous history of the individual.--_Melancholy,
eccentric, morose, &c._

2. Absence of motive.--_Gain, jealousy, revenge, hatred, &c._

3. A number of victims are often sacrificed at one
time.--_The murderer, on the other hand, seldom sheds
more blood than is necessary for his success._

4. Proceedings of the murderer before and after the
crime.--_Absence of attempts at concealment or escape
on the part of the madman._

5. Character of the victims.--_Not infrequently, in the
case of madmen, their victims are those whom, when sane,
they loved most, and to whom they were most attached._

_Suicidal Monomania, or the Propensity to Suicide._--Much discussion has arisen on this subject. Suicide is not always the result of unsoundness of mind. Some, like M. Esquirol, are inclined to consider suicide as always a manifestation of insanity. In the present day, the dislike of coroners‘ juries to bring in any other verdict but that of “suicide whilst in a state of unsound mind” is proverbial.

MELANCHOLIA

This condition is associated with mental depression and delusions. In its simple form, marked depression of spirits, apprehension of evil, sleeplessness, loss of appetite, and impaired alimentation with constipation are evident.

Delusions of ruin, of the committal of acts contrary to the laws of God and man--“_the unpardonable sin_”--a marked inaptitude to carry on the ordinary duties of life, indecision, and often unutterable misery, are commonly exhibited. The delusions are fixed and may be multiple. They may comprise persecution, by friends or others; that things are happening which powerfully influence the person‘s life and body, or, as is often the case, concern religious matters, and everlasting punishment.

Suicidal tendencies are often present, and depend largely upon the misery associated with the condition. Melancholics often conceal this tendency, or may exhibit it in varied ways so as to hide the method which has been definitely decided upon. Thus a person so afflicted may be found in possession of poison at one time, a pistol at another, a knife at another, when the real intention is that of drowning. Thus it is necessary to keep an extremely careful watch on melancholics. Homicidal tendencies are not common. In some cases the melancholia is combined with _marked agitation._ The face depicts misery, the eyebrows raised, and the person moves about incessantly, picking up objects and replacing them, moaning and uttering the same phrases expressive of misery and hopelessness, wringing the hands, and rocking the body to and fro.

In other cases _stupor_ is predominant, and the person sits in silence and in the same attitude. Some resent interference, others are easily persuaded by their attendants to do certain acts, but when done relapse again into stupor. They manifest extreme apathy. Suicidal tendencies are a pronounced feature of such cases.

Melancholia and mania may alternate periodically, with lucid intervals intervening. The term _circular insanity_ has been applied to this alternate character of the disease.

DEMENTIA OR FATUITY

=Dementia= consists in a failure of the mental faculties, not congenital, but coming on during life. “A man,” says Esquirol, “in a state of dementia is deprived of advantages which he formerly enjoyed. He was a rich man who has become poor. The idiot, on the contrary, has always been in a state of want and misery.” In this state there is always more or less coherence, and maniacal paroxysms are not infrequent. In mania, incoherence may be present, but then it is characterised by sustained and violent excitement. In dementia, on the other hand, there is apparent torpor and exhaustion of the mental faculties. Closely allied to this form of mental unsoundness is that interesting disease known as “=general paralysis of the insane=,” or perhaps a better term, _progressive paralysis of the insane._ It is considered by some to precede the psychical derangement, a contrary opinion being held by others. General paralysis may accompany any of the forms of mental derangement, but it is generally preceded by a stage of melancholy. As the paralytic affection becomes more marked, there is a concurrent loss of memory and incapability of mental association, and all sense of duty is lost; the patient becomes careless as to his person, and dirty in his habits. He expresses himself as possessed of great property, and boasts of the wonderful deeds that he can or has accomplished. Gradually he sinks into a state of complete mental and physical decay. He cannot give expression to his thoughts, and has to be fed, the food being pushed into his mouth. The symptom which first attracts the attention, and which is perhaps the first order of sequence, is a modification in the articulation. “This is neither stammering nor hesitation of speech. It more closely resembles the thickness of speech observable in a drunken man. It depends upon loss of power over the co-ordinate action of the muscles of vocal articulation.” If the tongue be now examined, it will be found that when it is protruded it is not inclined to one side, but that it is tremulous, and is protruded and withdrawn in a convulsive manner. Griesinger was the first to call attention to the fact, and his statement has since been confirmed, “that this motory disorder is at the commencement not so much paralytic as convulsive in its nature.” The gait becomes unsteady, the patient walks stiffly, and stumbles over the slightest unevenness in the floor. Step by step the paralysis progresses, till at last the unfortunate sufferer takes to his bed, on which he may lie for months. Sometimes, especially during the earlier stages, he may suffer from terrible delusions, from maniacal paroxysms, or from epileptic fits, the latter possessing certain peculiarities. The tongue during the fit is seldom bitten, which is so commonly the case in epilepsy; and the convulsions are not so general, being limited more to one side than to the other. It is also remarkable that each fit is in most cases followed by an increase of the mental derangement.

Pritchard recognises four stages of dementia or fatuity:--

_First Stage._--Forgetfulness and impaired memory. This is common to old age. In most cases passing events produce little, if any, impression, whilst the past is remembered with tolerable freshness.

_Second Stage._--Incoherence and unreason, characterised by a total loss of the reasoning faculty.

_Third Stage._--Incomprehension. The person so affected is quite incapable of comprehending the meaning of the simplest question; and should he attempt to reply, his answer is generally remote from the subject.

_Fourth Stage._--Inappetency. The animal instincts are lost. The unfortunate sufferer lives, and that is all, being scarcely conscious of life. Organic life is all that is left.

DELIRIUM TREMENS. SIMPLE DELIRIUM. SOMNAMBULISM. SLEEP-DRUNKENNESS.

=Delirium Tremens.=--A temporary form of insanity, the result of excessive indulgence in spirituous liquors. The drunkard, under the effects of intoxication, “can derive no privilege from a madness voluntarily contracted, but is answerable to the law equally as if he had been in full possession of his faculties at the time” (1 Hale 32; Co. Litt. 247). The intoxication of the defendant may be taken as a mitigating circumstance, showing that the deed was unpremeditated. A person rendered incapable of using his reason by intoxication brought about by others, is not liable for his actions.

=Simple Delirium.=--Acts performed during attacks of certain diseases--fever, sunstroke, &c.--accompanied with delirium, do not render the individual liable to punishment; and wills made during the continuance of the disorder, if they contain no statement inconsistent with the known wishes and desires of the party during health, are valid, the law looking more to the good sense of the will as a proof of a lucid interval, than to the proved existence of such lucid interval.

=Somnambulist, &c.=--This is an abnormal mental state, closely allied to that artificially produced and known under the names of mesmerism, hypnotism, electro-biology, &c. It is commonly known as “sleep-walking.” In this condition the mind appears to become enslaved by one train of ideas to the exclusion of all others; the somnambulist, thus deeply bent on the accomplishment of a definite end, takes no heed of those objects which are in no way connected with the dominant ideas in his mind. Hence, he walks safely past dangers which, when awake, would disconcert his judgment and weaken his will. Somnambulism appears also to be closely connected with epilepsy. In 1878, a man named Fraser was tried in Glasgow for the murder of his child by beating it against the wall. He was acquitted on the ground of being unconscious of the nature of his act by reason of somnambulism. He had sprung from an epileptic and insane stock; his mother died in an epileptic fit, and some of his other relatives were insane. Thus it appears, if the somnambulism be proved, the accused is exonerated from any responsibility connected with the act for which he is being tried. So also, if a person be suddenly aroused from a deep sleep--_somnolentia_ or _sleep-drunkenness_--the question may be raised as to his responsibility for an act committed at the moment of awakening (R. _v._ Milligan). There cannot be a doubt but that if a person be suddenly aroused whilst dreaming, he may unconsciously commit acts, the outcome of his dream, which, unless the possibility of this condition be recognised, may entail severe punishment on him. This state is closely allied to that mental condition which sometimes occurs in epileptics immediately after a fit. But in this, as in cases of somnambulism, the facts of the case would have to be most carefully scrutinised.

The following hints may be of use as a guide in determining the responsibility or not of the accused:--

1. The person must be shown to have a general tendency to
deep and heavy sleep, out of which he can only be aroused
by a violent and convulsive effort.

2. Are there any circumstances which, happening before
the individual went to sleep, would produce a train of
disturbed thought not entirely composed by sleep?

3. Did the act occur during the usual hours for sleep?

4. Was the cause of the awakening sudden, and does the act
bear throughout the character of unconsciousness?

5. What were the subsequent acts of the accused in relation
to the deed? Did he try to evade responsibility? This
must not have too much stress laid upon it, for the
wretchedness of the sudden discovery may so overcome him,
that he may seek to shelter himself from the consequences
of an act for which he is legally but not morally
responsible.

THE RESTRAINT OF THE INSANE AND DIRECTIONS FOR SIGNING MEDICAL CERTIFICATES.

No person can be put under restraint unless the conditions required by the Lunacy Acts are fulfilled. The Acts of Parliament for this purpose are the Lunacy Act of 1890 (53 Vict. c. 53) and that of 1891 (54 and 55 Vict. c. 65). Lunatics may be put under restraint by the following procedures, according to the particular case:--

Reception Order on Petition.
Urgency Order.
Order after Inquisition.
Summary Reception Order.
Order for Lunatics Wandering at Large, and for Pauper Lunatics.
Reception Order by Two Commissioners.

=Reception Order on Petition.=--This is usually the procedure for private patients. The order for petition may be obtained from a specially appointed Justice of the Peace, Judge of County Courts, or Magistrate. A petition for the order must be presented to the Judicial Authority by the husband, wife, or relative of the alleged lunatic; if any other person apply, the reasons for this must be given. A petitioner must be twenty-one years of age or over, and must have seen the alleged lunatic _within fourteen days_ before its presentation. A _statement of particulars_ and two medical certificates must accompany the petition. The proceedings are private, and no one except the petitioner, the alleged lunatic, and any one person appointed by him, and the two medical men who have signed the certificates, may be present, unless by permission of the Judicial Authority. If the Judicial Authority be satisfied, he may make the order at once, even without seeing the patient, or he may appoint a time within seven days for inquiries and consideration. He may visit the alleged lunatic.

At the time of consideration of the petition he may adjourn it for not more than fourteen days, or he may make the order at the time. He may summon further witnesses, or dismiss the petition, giving his reasons for so doing in writing.

A reception order is valid for seven days from its date, unless the lunatic is certified by a medical man to be unfit for removal, when the order is extended until a medical certificate of fitness for removal is obtained, which is valid for three days.

The medical men signing the certificates must not be in partnership, as principal and assistant, or have any direct or indirect interest in the patient or his keeping (16 and 17 Vict. c. 96, sec. 4). They must make separate visits at different times for the purpose of examination. Each medical man must have examined the person within seven clear days before the presentation of the petition.

Each medical man must write clearly and in the proper place on the certificate: (1) The facts observed by himself as evidence of insanity, and (2) the facts observed by others as evidence of insanity. The name of his informant must be given.

One of the certificates should, whenever practicable, be under the hand of the usual medical attendant (if any) of the alleged lunatic. If not practicable, the reason must be given by the petitioner to the Judicial Authority.

Neither of the certifying medical practitioners may be the father or father-in-law, brother or brother-in-law, sister or sister-in-law, partner or assistant of the other of them.

Great care should be taken to follow carefully the marginal directions on the certificate form. The most trivial omission will invalidate the certificate. The omission of the name of the street and number of the house is sufficient to set it aside. A medical man should remember that, although his certificate may have passed the scrutiny of the Commissioners, it is liable to be made the subject of discussion in a Court of law, and in cross-examination he will have to support the statements therein made.

The following certificate properly filled up by Dr. Millar of Bethnal House Asylum, is given in his book on _Hints on Insanity_, and may be taken as an example of a correct certificate at that time, the present form being slightly different:--

MEDICAL CERTIFICATE PROPERLY FILLED UP

1. _Here set forth the_ I, the undersigned,
_qualification entitling the_ _John Millar_, being a (¹)
_person certifying to practise_ _Licentiate of the_
as a physician, surgeon, _or_ _Royal College of Physicians_,
apothecary. _Edinburgh_,

2. Physician, surgeon, _or_ and being in actual practice as
apothecary, _as the case_ a (²) _Physician_, hereby certify
_may be_. that I, on the _third_ day of
_November, One thousand eight
hundred and eighty-eight_,
at (³) 600 _Cambridge Road_,
3. _Here insert the street and_ _Bethnal Green_, in the county of
_number of the house (if any_), _Middlesex_, separately from any
or other like particular. other medical practitioner,
personally examined
_James Thompson, sen._, of
4. _Insert residence, and_ (⁴) 600 _Cambridge Road_,
_profession or occupation_ _Bethnal Green_, _gentleman_,
_(if any)._ and that the said _James Thompson,
sen._, is a person (⁵) _of unsound
5. Lunatic, _or_ an idiot, mind_, and a proper person to be
_or_ a person of unsound mind. taken charge of, and detained
under care and treatment; and that
I have formed this opinion upon
the following grounds, viz.:--
6. _Here state the facts._ 1. Facts indicating insanity
observed by myself (⁶)--
_He is incoherent in his
conversation, violent in his
conduct, and quite unable to
take care of himself_.
7. _Here state the information,_ 2. Other facts (if any)
_and from whom._ indicating insanity
communicated to me by
others (⁷)--
_His son, James Thompson, jun_.,
_informs me that he has_
_threatened to commit suicide_,
_and has twice attempted it_
_with a razor._
(Signed) Name--_JOHN MILLAR_.

Place of abode--_Bethnal House_, _Bethnal Green_.

Dated this _third_ day of _November_,
_One thousand eight hundred and eighty-eight_.

The following are examples of “Facts” sent back to be amended by the Commissioners--the emendations in italics:--

1. Incoherence, perversion of facts, delusion. _Fancies
that he possesses large amounts of money which people
have secreted from him._

2. Says her sister lives in Chiselhurst, and she fears she
is dying. She took great notice of my feet, and remarked
that they were very large. Query by Commissioner--Are
these delusions? _Her sister does not live at Chiselhurst,
and is perfectly well; my feet are not large._

3. General restlessness of manner; considers himself heavily
involved in debt to many thousands of pounds, _whereas
his debts do not amount to a few hundreds_; says he
has been ruined by the Government, _whereas he has
only been dismissed from his appointment on account
of his incapacity_; and he intends prosecuting the
Admiralty for £5000 damages, _he having no real ground
of action_. (This was twice sent back for correction,
the first correction being--_By these statements I
was satisfied that the patient was of unsound mind, and
by his general conduct during examination._ Finally
amended as given above.)

[Sidenote:

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Text-book of forensic medicine and toxicologyChapter XVI: Mental Unsoundness (1)

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