CONTRIBUTION TO 
MENTAL PATHOLOGY. 
Bv Edward C. Mann. M. D., 
Member of the Neva York Neurological 
Society. Medico-Legal Society, etc. 
New York. 
Reprint from 
The Alienist and Necrologist, 
St. Louis, Octobei, 1881. Contribution to Mental Pathology. 
Codification of the Common Law as to Insanity. 
By Edward C. Mann, M. D., New York,* 
MEMBER OF THE NEW YORK NEUROLOGICAL SOCIETY, MEDICO-LEGAL 
SOCIETY, ETC. 
T AM sure that the acute minds of many of our most 
distinguished physicians and lawyers have not failed 
to perceive the incongruities and deficiencies of the 
present law, and yet there are many who seem adverse 
to any attempt to make the law of insanity more com- 
formable than it is with medical science. Lord Justice 
Bramwell told the select committee on the homicide bill: 
“ I think that although the present law lays down such a 
definition of madness that nobody is hardly ever really 
mad enough to be within it, yet it is a logical and good 
definition.” He further stated that in his opinion, “ the 
law was right, because it might deter many insane 
persons from crime by the threat of punishment.” Lord 
Justice Blackburn, in his testimony before the select 
committee on the homicide bill, said : “ On the question 
of what amounts to insanity that would prevent a 
person being punishable or not, I have read every 
definition which I could meet with, and never was satisfied 
with one of them, and have endeavored in vain to make one 
satisfactory to myself. I verily believe that it is not in 
human power to do it. You must take it that in every 
individual case yon must look at the circumstances and do 
the best you can to say whether it was the disease of 
the mind which was the cause of the crime, or the party’s 
criminal will.” He also said: “ but we cannot fail to see 
that there are cases where the persoyi is clearly not respon- 
sible, and yet knew right from wrong.” 
* Physician to Suunyside: a private hospital for nervous and mental diseases, 
inebriety and the opium habit. _ — ~^ 2 
Edward C. Mann. 
He then goes on to give the case of a woman he tried, 
who had killed one child, and was going to kill another, 
but who fortunately dropped the second child and went 
to a neighbor, telling her what she had done. This 
woman clearly knew the difference between right and 
wrong, and knew the character of the act, and, on the 
definition in the McNaughton case, in 1843, was guilty. 
Lord Justice Blackburn, however, as the woman was as a 
raving maniac, so charged the jury on the ground of 
exceptional cases, that the jury found her “ not guilty, 
on the ground of insanity;” and rightly. The Lord Chief 
Justice of England, in his criticism of Sir Fitzjames 
Stephenson’s plan of codifying the law of insanity, said: 
“ As the law, as expounded by the judges in the House of Lords, now 
stands, it is only when mental disease produces incapacity to distinguish 
between right and wrong, that immunity from the penal consequences ot 
crime is admitted. The px-esent bill introduces a new element, the 
absence of the power of self-control. I concur most heartily in the pro- 
posed alterations of the law ; having been always strongly of opinion that, as 
the pathology of insanity abundantly establishes, there are forms of mental 
disease in which, though the patient is quite aware he is about to do wrong, the 
will becomes overpowered by the force of irresistible impulse; the power of 
self-control, when destroyed or suspended by mental disease, becomes, I think, 
an essential element of responsibility.” 
The Lord Chief Justice of England, in his weighty 
and truly scientific opinion, the intrinsic weight of which 
is immense, deserves the admiration of both the medical 
and legal profession all over the world. Lord Moncrief, 
the Lord Justice Clerk of Scotland, has said from the 
bench that “in point of fact, there are very few lunatics who 
do not know right from wrongf an opinion which I have 
myself insisted on before the New York Medico-Legal 
Society in two different papers read there. If we have 
the absence of self-control produced by disease of the body 
affecting the mind, in any given case of homicide on trial, 
it seems to me that every physician and every fair-minded 
lawyer will concur in acknowledging that we have here a 
philosophic or scientific principle on which to found the 
plea of “ not guilty, on the ground of insanity,” and one 
which includes the cases of all insane criminals. It does Contribution to Mental Pathology. 
3 
not seem to me that, in the question of what constitutes 
insanity, the members of the two great professions of 
law and medicine should, or at all need to, entertain 
essentially different and irreconcilable views, or that on 
the question of the irresponsibility of criminals who are 
supposed to be insane, there should be such a diversity 
of opinion as exists to-day. The physician naturally 
studies the whole history of his patient and his ancestry, 
and searches for the causes of any bodily and mental 
changes that he finds, and thus arrives at the true 
pathology of the disease ; while the law}rer and jurist are 
mainly interested in the existence of mental disease, its 
degree, and its influence on conduct. We know far more 
about insanity than they did in the last generation, and 
it is obviously unfair that laws pertaining to insanity, 
when the knowledge of that disease was comparatively 
in its infancy, should not be amended to keep pace with 
our increased knowledge of the pathology of mental 
disease. In that form of homicidal monomania, where 
the patient is possessed of a sudden, blind, motiveless, 
unreasoning impulse to kill, I do not think that there is 
any desire, motive or reasoning intention to commit such 
a deed, the true pathology of this form of insanity 
consisting, it seems to one, in a vis a tergo received from 
the diseased action of the brain. We have here a diseased 
state of mind with absence of self-control. We have in 
suicidal monomania also, a vis a tergo received from the 
diseased action of the brain, in which, while our patient, 
perhaps, exhibits no other mental derangement, with no 
delusion or other intellectual disorder, has the blind, 
motiveless, unreasoning impulse to suicide, which, alike 
with the homicidal impulse, is the joint result of undoubted 
insanity. In both these cases the impulse is long, 
enduring and gives rise to actions of patient deliberation 
and of cunning contrivance. The physician and the 
legal profession are willing alike to recognize disease in 
the suicidal act; why, then, the apparent unwillingness 
to recognize disease in the homicidal act? We must not 4 
Edward C. Mann. 
look at these questions socially or ethically, but by the 
aid of the light of modern pathology, as the Lord Chief 
Justice of England has done already. There are many 
persons born with a predisposition to madness, and 
symptoms indicating that disease, display themselves at 
frequent intervals through the whole course of life, but 
for many years may never reach such a pitch as to 
induce those in contact with such persons to treat them 
as insane. When an overt act is committed by such 
persons can anyone question the value of a careful examina- 
tion of the past life and acts of the accused ? His life 
has exhibited the natural history of insanity, and, with 
our present accurate and trustworthy method of investi- 
gation, a careful and experienced physician in nervous 
diseases can clearly point out to the lawyer and jurist 
the unmistakable evidences of mental disease, which the 
latter, necessarily, alone and unaided, could not discover. 
The physician and lawyer should mutually aid each other 
in such investigations, impartially and by the light of 
science. There should be no rule of law that conflicts 
with the elementary truths of insanity, on which only 
such rules should be founded, and medical jurisprudence 
is of value only so far as it represents the acknowledged 
truths of science. No honest, scientific conclusion, 
however great an advance it may be upon existing views, 
is a dangerous innovation. There is a very false idea in 
the minds of well educated persons, which I desire here 
to correct, that the skilled opinions of the medical witness 
—the result of years of reflection and experience in his 
particular specialty—that the perceptions of truth of the 
medical expert are obscured by the fact of his receiving 
a fair compensation for his services. The medical expert 
is called upon by the lawyer who lays before him the 
evidence to be produced, and asks him for his opinion 
respecting it. The physician informs him either, that if 
he can prove the facts as he states them, he has a good 
case, and expresses his willingness to testify to that 
effect, or he tells him that the facts of the case do not Contribution to Mental Pathology. 
5 
justify the construction which the lawyer desires to put 
upon them, and declines to testify in the case. 
The testimony of an honest medical expert is never 
wholly and unconditionally in favor of one side only, 
unless such a result be warranted by the facts. His judg- 
ment is not warped by the fact of his receiving compen- 
sation. If a lawyer comes to the physician and, by an 
exaggerated statement of facts, enlists the physician’s aid 
as a medical witness, he will find that, if upon an examin- 
ation of the case the facts do not appear as represented 
to the physician, the latter, if a scientific man, will either 
modify or entirely abandon his first conclusion, and decline 
to testify in the suit. 
The frequency of epilepsy, and its injurious effect 
on the mind, makes its medico-legal relations a subject of 
great importance, and I have elsewhere pointed out that 
epileptics are to be classed in the most homicidal group 
of all the insane. 
The late Dr. Ray, of Philadelphia (one of the most 
eminent of American experts, and one of the most 
brilliant and scientific men of the profession, a man who 
had devoted himself to the study of mental pathology 
for years, and who, in his writings, always displayed 
thorough observation and original thought; and to whom, 
in his contributions to mental pathology, his friends can 
fitly apply the words of Sartor Resartus: “ Beautiful it 
is to understand and know that a thought did never yet 
die, that as thou, the originator thereof, hast gathered it 
and created it from the whole past, so thou wilt transmit 
it to the whole future,") speaks as follows respecting 
epilepsy: 
“ The excessive susceptibility of epileptics to nervous impressions, 
which become distorted it not utterly changed on their way to the 
sensorium, is a phenomenon not clearly recognized by the profession at 
large, although it cannot have failed to meet the attention of the closer 
observer. In medico-legal inquiries, it should never be ignored or 
forgotten, for it may be the very phase of mental disturbance which 
prompted the criminal act. In view of what we already know of epilepsy, 
and of what still remains to be learned, we have a right to require the 
utmost circumspection and closest investigation whenever the legal 6 
Edward C. Mann. 
liabilities of epileptics are in question. The fact of its existence being 
established, is it going too far to say that legal responsibility is presump- 
tively annulled, and that the burden of proof lies on the party that alleges 
the contrary? People are scarcely ready for it yet, perhaps, but to that 
complexion must they come at last.” 
In none of the neuroses is the presence of the elements 
of moral obliquity, emotions of suspicion as the mainspring 
of conduct, maniacal fury, sudden ebullitions alternating 
with periods of lucidity, suicidal or homicidal mania, so 
conspicuous as in epileptic insanity. Esquirol says that 
out of 339 female epileptics treated in Charenton, only 
sixty exhibited no aberration of intelligence. An epileptic 
convulsion may not occur, but may be represented by 
sadness, dejection, by sullenness, by ebullitions of rage 
and ferocity—a mania transitoria signalized by suicide, 
homicide, and every modification of blind and destructive 
impulse. Trousseau, the great French physician, has 
said, that wherever there was a revolting or motiveless 
crime, he suspected the existence of epilepsy; and the 
late case of Laros of Pennsylvania, who poisoned his whole 
family, is an example of just such cases. The awakening 
from epileptic stupor may often resolve itself into an 
outburst of mental derangement, manifested by extreme 
vehemence, violence and destructiveness. 
I have also stated that puerperal women, and women 
at the climacteric period are subject at times to dangerous 
delusions, and also that kleptomania is a peculiarity of a 
certain number of cases of general paralysis. These facts 
are classical, and should be so accepted by the legal 
profession. One of the last cases of general paralysis 
under my care, was that of a gentleman of prominence 
and wealth, who would slyly secrete articles of absolutely 
no value to himself and carry them home, and who, after 
being placed under my care, manifested this peculiarity 
for many months, so that his nurse would every few days 
have quite a collection of small articles to gather up and 
return to their appropriate places. I have observed this 
in cases of the ordinary type with grand delirium, and 
also in the senile form, characterized by progressive Contribution to Mental Pathology. 
7 
enfeeblement of the intellect and of long duration. It is 
a very interesting question in mental pathology, whether 
we are entitled to hold, in general paralysis of the insane, 
that the resumption of apparently healthy mental action, 
which we see in the remissions that sometimes occur, is 
compatable and co-existent with persistent structural 
degeneration ? In other forms of mental disease also, 
after a mental darkness created and maintained for years 
by the presence of brain wasting, hypertrophy or consol- 
idation of brain-tissue, with what cerebral condition can 
we identify these sudden flashes of restored intellectual 
light? In a paper on “Mental Responsibility and the 
Diagnosis of Insanity in Criminal Cases,” read before the 
New York Medico-Legal Society, and subsequently 
published in the London Journal of Psychological Medicine 
and Mental Pathology, I suggested a series of eight 
questions, which, it seemed to me if adopted by jurists 
in criminal cases, would form a most efficient and just 
test in any given case. Perhaps the legal profession may 
prefer the simpler proposition, which, as the result of Sir 
Fitzjames Stephen’s attempt to codify the common law 
of England on insanity, may be briefly summed up as 
follows, viz : Homicide is not criminal, if the person by whom 
it is committed is, at the time when he commits it, prevented by 
any disease affecting his mind from controlling his own conduct. 
This is very simple and very comprehensive, and therefore 
the legal profession may very properly prefer it to my 
own. The eight questions which I proposed in my paper 
are as follows, viz: 
1st. Have the prisoner’s volitions, impulses or acts been determined 
or influenced at all by insanity, and are bis mental functions—thought, 
feeling and action—so deranged, either together or separately, as to inca- 
pacitate him for the relations of life? 
2d. Does the prisoner come of a stoek whose nervous constitution 
has been vitiated by some defect or ailment calculated to impair its 
efficiency or derange its operations ? 
3d. Has the prisoner been noticed to display mental infirmities or 
peculiarities which are due either to hereditary transmission or present 
mental derangement ? 
4th. Has the prisoner the ability to control mental action, or has 
he not sufficient mental power to control the sudden impulses of his 8 
Edward C. Mann. 
disordered mind, and does he act under the blind influence of evil impulses, 
which he can neither regulate nor control ? 
5th. 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? 
6th. Was the act effected by, or the product of insane delusions? 
7th. Was the act performed without adequate incentive or motive? 
8th. Does the prisoner manifest excitement or depression; moody, 
difficult temper; extraordinary proneness to jealousy and suspicion; a 
habit of unreasonably disregarding, ordinary ways, customs and observ- 
ances; 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. Centainly, if we take these manifes- 
tations in No. 8, 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 circum- 
stances, 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 disappointments 
and calamities of life obviously act with greater effect 
upon an unstable mental organism; these causes of 
disturbances, meeting with a powerful cooperating cause 
in the constitutional predisposition. Sometimes a crime, 
even when there have been no previous symptoms to 
indicate disease, makes the period when an insane tend- 
ency has passed into actual insanity—when a weak organ 
has given way under the strain put upon it. It is an 
important point in mental pathology to recognize the fact, 
rendered classical by antiquity—Celsus, who practiced 
during the reign of Tiberius, and who wrote eight books 
on medicine, having clearly expressed this law of morbid 
sympathies and idiosyncrasies—that it is the diseased or 
weak organ that retains all too strong impressions that 
effect the economy, and which becomes the center with 
which are connected all the sensations and all the 
disorders communicated to the body. The laws of Contribution to Mental Pathology. 
9 
hereditary transmission operate very often in the devel- 
opment, in successive generations of the same family, of 
an unstable mental organism, too delicate to stand the 
wear and tear and haste of modern civilization, and such 
persons also often exhibit a true congenital deprivation 
of the normal intellectual faculties. 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 prepon- 
derance 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 organization, 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 function. I have 
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 degeneration 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. It is an 
important medico-legal point relating to psychological 
medicine, that not every improvement is the commence- 
ment of convalescence, nor is the appearance of a few 
healthy traits an unquestionable presage of recovery. It 
is not rare to find a complete remission, consisting in 
the temporary disappearance of every sign of mental 
disease during the first month of an attack of insanity, 
followed by a renewed intensity of the disease. 
This, of course, is no more a recovery from disease 
of the brain, than the remission in malarial fever is 10 
Edward C. Mann. 
indication of recovery from malarial fever. I have 
repeatedly witnessed such remissions even in incurable 
organic diseases of the brain. We cannot explain these 
cases, but that they occur is perfectly well known to 
every specialist in diseases of the nervous system, as 
well as to most observant physicians. It should be borne 
in mind, therefore, that there may be a condition of mind 
resembling recovery, but where there is a latent irritability 
of the brain ready to break out in active insanity, were 
not such persons prevented from assuming the cares, 
anxieties and responsibilities of life for themselves. 
Unreasonable and uncontrollable restlessness and excite- 
ment or depression generally characterizes these apparent 
recoveries, and also very often a peculiar bitterness towards 
the institution where they have been treated with all 
gentleness and skill; whereas, in genuine recoveries, it is 
the rule to find patients entertaining the most lively 
gratitude to their physician and toward the institution in 
which they were treated. Dr. Pliny Earle, of Northampton, 
Mass., one of the most eminent American alienists, the 
late Dr. Ray of Philadelphia, and the most eminent 
pnglish alienists have all expressed themselves unanimously 
on this point. 
There are forms of chronic insanity in which the 
mental manifestations are distinguished less by delusions 
and gross incoherence, than by a certain mental irregu- 
larity and unsteadiness easily recognized by one familiar 
with diseases of the brain, where the mind is agitated and 
controlled by each new impulse; and yet this form of 
mental disease under our present law is clearly incom- 
patible with the kind of insanity which annuls criminal 
responsibility, for, as a rule, all these cases of which I 
speak can clearly distinguish between right and wrong. 
Finally I would speak of the immense importance of 
the recognition of the mental condition that is the 
precurser of decided insanity. This is one of the most 
interesting points in mental pathology. The depression, 
unwonted excitability, disregard of the minor proprieties Contribution to Mental Pathology. 
11 
of life, the change which comes over the warmest affections, 
quick changes and rapid transitions in the current of the 
feelings, sleeplessness and a complete change of character 
and habit; the person meanwhile entertaining no delusions, 
but occasionally losing his self control, the general air 
and manner at such times being strongly expressive of 
the inward emotion; intervals of perfect calmness and 
self-control, during which the person clearly discerns his 
true relations to others, and even, perhaps, recognizes the 
influence which the incipient disease exercises over his 
feelings and actions ; with, finally, the utter downfall of 
the integrity of the intellect, manifested by the fury of 
mania or the moodiness, suspicion, depression, and 
impulses toward self-destruction of melancholia. All 
these are the successive links forged in the chain of insanity, 
the study of which is full of interest to the student of 
mental pathology, who is interested in the amelioration of 
this scourge of life, and to those who are interested in 
leading back the wandering mind out of the darkness 
and mazes of disease into the unclouded light of reason. 
Such aims are worthy of the warmest sympathy, the 
deepest respect, and the strongest help of the community. Every intelligent Physician and. Medical Student should subscribe 
for “The Alienist and Neurologist.” 
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