The Claim of Moral Insanity in its Medico-Legal Aspects BY JAMES HENDRIE LLOYD., M.D. INSTRUCTOR IN ELECTRO-THERAPEUTICS IN THE UNIVERSITY OF PENNSYLVANIA Reprinted from The Medical Record, May 14, 1887 NEW YORK TROW’S PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1887 The Claim of Moral Insanity in its Medico-Legal Aspects. By JAMES HENDRIE LLOYD, M.D., INSTRUCTOR IN ELECTRO-THERAPEUTICS IN THE UNIVERSITY OF PENNSYLVANIA. Reprmtcd. from The Medical Record, May 14, 1887. In the experience of the writer, which is largely based upon nearly three hundred cases of insanity, it has not been his fortune to see one case which answers to the descrip- tion, given in the books, of moral insanity. The three hundred cases cited have all been studied with care for the purpose, chiefly, of certifying, under the law, to their mental condition. In most of them the antecedent his- tory was attainable, and in many of them any unusual developments in their subsequent careers would prob- ably have reached the writer’s knowledge. These cases presented, I believe, all the recognized forms of insanity as laid down in all the classifications now in fashion. They came from all grades of society ; some were com- mitted to pauper asylums, some to the most select pri- vate and public institutions, and a few to an institution for feeble-minded children. They were representative of a very large insane population, because the writer for- merly had the advantage of certifying almost all insane paupers of Philadelphia, and continues, through the kind- ness of the medical officers, to make out certificates of insanity for many patients coming from other States to 1 Read before the Philadelphia Medical Jurisprudence Society, April 12, 1887. 2 asylums in or near this city, as well as to be retained not infrequently in private consultation for the same pur- pose. Records of all these cases have been preserved, and especially interesting features or unusual symptoms have been noted. In addition to the above cases the writer has studied a large number of brain cases during five years’ attendance upon the Nervous Dispensary of the University Hospital. In an experience of this kind it could not be expected that no evidence of moral obtuse- ness or obliquity had been observed; far from this, the most diverse and extraordinary perversions of the moral ideas have been noted, just as perversions of all other cerebral activities have been recorded, but no case has been found in which that pure and simple dislocation of the moral nature existed, without lesion of the under- standing, which we are led to believe by some writers is a not unusual form of insanity—especially of criminal in- sanity. It will be, therefore, the object, in part, of this paper, to compare briefly some of these cases of the writer with a very few of the most important cases men- tioned by some of the most prominent writers who have described moral insanity. I conceive this subject to have importance in two aspects. It has importance, first, to the medical nosolo- gist, or him who classifies and describes disease. It has still more importance to the medical jurist, or him who studies the actual legal relations of disease. With the first the subject is apt to degenerate into a mere quibble about terms. To the latter it presents itself as the most responsible question of fact. It thus appears that a brief definition of terms is of primary importance, while later it will be appropriate to make a short clinical analysis of cases and draw from them their proper deductions in medico-legal science. It is not my intention in this paper to indulge in meta- physical abstractions, but it is imperative at once to con- sider briefly certain terms and distinctions which are con- stantly applied to this subject by medical writers, and 3 which terms they have indubitably borrowed from the metaphysicians and theoretical psychologists who have been for generations thrashing this ground over and over again to find little wheat and much chaff. According to most of these speculators the mind is divided into (i) the intellect, (2) the emotions, and (3) the will. The “ mind” itself is regarded by some of them as something imma- terial, individual, and distinct from the organic brain. Each of these faculties has come to be treated in most systems as though it were a distinct thing in itself, with its own peculiar functions and diseases, just as the heart is a distinct viscus of the body apart from the arm, which, in turn, has its own partial independence. That such a division may have facilitated the study of abstract psy- chology, and may even yet furnish many convenient terms and much smooth rhetoric for the medical nosolo- gist, is not to be doubted, but I think I am not mistaken when I say that the distinction is an entirely arbitrary one, and that there has never been offered an iota of evidence in anatomy, physiology, or pathology that these so-called “ faculties of the mind ” are anything more than varying phases or modes of action of one identical sub- stance—the cerebrum. So thoroughly engrafted upon medical science is this creed of the metaphysicians that our books abound with classical descriptions of “intel- lectual ” insanity as apart from “ emotional ” insanity, and a disease of “ the will ” has even been depicted un- der the dreadful name of abulimia. This latter so-called disease I saw exhibited in a poor woman who was suffer- ing with melancholia, and had been cruelly treated and deserted by her husband. She stood in a corner of the room; she apparently could not speak nor perform any ordinary action. She was certainly without will or the active manifestation of it; but who can doubt that her mind was overwhelmed with depressing and stupefying ideas in which her intellect and emotions were hope- lessly jumbled ? Another case has been recorded of a man who sat immobile for a long time, having appar- 4 ently lost his metaphysical “ will,” but who was found to be harboring the delusion that his body was glass and his only safety was in rest. The last effort of this doctri- naire school seems to have been in the direction of the conscience, or moral nature. Some call the moral nat- ure a part of the emotions, while others give it a distinct place in classification, and this has led to corresponding confusion in moral insanity. With some it is purely an “emotional” insanity, with others it is “instinctive,” with others it is a sort of abulimia, or loss of will, as in the “ impulsive ” varieties, etc. It is thus seen that there is much looseness with confusion of terms here, which is always suggestive of a confusion of thought. It is also apparent to my mind that in the cases reported by these writers there has been no strict, searching analysis of symptoms, or else the symptoms have been put down with strong bias in favor of the artificial classification employed. A few weeks since a man came to the writer in great distress of mind, and said that as he was shaving one day recently the thought suddenly occurred to him that he might cut his throat, or possibly his wife’s throat. He could not account for the thought, and neither could he cast it off, but was constantly haunted by the fear that he would yet commit one or both of these terrible acts of violence. If this man were to commit these acts he would probably be called by some writers a case of im- pulsive or motiveless insanity, in which, according to their favorite theory, his intellect would not be affected. Now it seems to me that this patient had a so-called impera- tive conception, which was delusional in character, and that he was in fact in a state of mind not unlike the hypo- chondriac who is constantly terrorized by the dread of what may be. This imperative conception is his motive, and if he falls a victim to it he is insane. The act would be as intellectual as any brain-act. The truth about the brain-hemispheres, as far as we know it, seems to be that they are the seat of a special, 5 highly differentiated reflex act. That they are, in fact, highly organized and developed masses of nerve-sub- stance—which have probably by a process of evolution grown from the likeness of one of the inferior ganglionic masses to their present huge proportions and superior dignity, and that they are in no way exempt from the law, governing all nerve-centres, that upon excitation alone from without there comes a reflex act from within. This is, in other words, the law that upon sensation comes reflection, and is practically what was taught by Locke and Condillac, long before the era of Charles Bell or Marshall Hall, which is a curious confirmation of the truth that philosophic insight has often gone before scientific inquiry to demonstrate a fact. This highly specialized reflex act goes under a great variety of names, and is called memory, thought, intellect, reason, medita- tion, imagination, passion, will, talent, genius, etc., ac- cording to the point of view taken by the outsider rather than because of any known anatomical or histological changes or differences which take place in the insider. In other words, this special act has been given a legion of names according to its many and various phases, while in itself it can always be reduced simply to the condition of a reflex act, i.e., perception, comparison, and action. This specialized act of the cerebral masses was named, I believe by James Mill, ideation; and as doing away with the innumerable aitificial terms of the pseudo-psychologists, and being applicable to every con- ceivable mental act, it is the one for which I think med- ical writers ought especially to be thankful. From what- ever point of view we take the human mind (by which I mean the human brain) we see it always reducible to this one term ; for whether it meditates upon the highest problems of destiny or is tossed (metaphorically) with the stormiest passions of love or hate, it is essentially in the process of comparison, leading from perception to action, which conjoint act is this special process called ideatioti. Its diverse manners of acting, according to 6 the character of the external objects which excite it, do not alter the essential unity and individuality of this special act. And yet it is according to its various modes merely that the classical and artificial distinctions have been made, by which even yet some practical alienists endeavor to steer their course, instead of by a more rational study of the identical acts of the brain itself— whose confusion, exaltation, depression, perversion, or disorganization can alone constitute either a scientific or a legal insanity. I have never yet seen in actual practice a case of so- called moral insanity, or read the descriptions of such in the books, that it has not seemed easy to me to detect the fallacy which ascribes to such cases a normal intellect amid the ruins of the shattered soul. The following case was seen in Moyamensing Jail some six years ago, and has once since made some stir in the newspapers. A. B had fallen from his horse in boyhood and injured his head. He had preserved fair brain-power, and when he grew up had learned a profession, at which he attempted, without success, to practise. But he had grown up, nevertheless, a crooked stick, and was regarded by ac- quaintances as odd, ugly dispositioned, unreliable, and a crank. Upon a superficial view he fulfilled to the letter the role of a moral lunatic; in fact he did out-herod Herod, and was a much better specimen of his class than is usually reported. He lived comfortably at the ex- pense of his unmarried sisters, and talked so well that persons associated with him for months and did not sus- pect his mental integrity. He was affable to strangers, but of such rude and hasty temper to his family as to cause them sometimes alarm lest he should assault them. At last he began to excite a disturbance in the family about his father’s estate, which had been divided and settled equitably years before, and announced that he had been defrauded of his share. In order to bring his sisters to terms he deliberately began to malign the repu- tation of one of them—who was a most estimable wife 7 and mother—and set up an atrocious scheme of black- mail. When this became unendurable his family had him committed to jail to keep the peace, and in jail I signed his certificate, with a brother physician, to send him to Norristown Asylum. On examination of this man I found he had little correct reasoning power on any sub- ject in which especially his own interests and relations were concerned, and that his disgusting egotism had culminated in a series of delusions of persecution in which he was as fixed as the earth in its orbit. If this man’s intellect was not affected, it must indeed have been of the metaphysical variety in a literal sense, and have kept out of sight far above the physics of Moyamen- sing Jail when I saw and examined him. He who has read Pinel on “ Insanity,” and has also a taste for the romance of history, has no doubt been pleased to find that author’s science so illustrated with the events of the French Revolution. That momentous period made many men mad, and Pinel gives us many glimpses into some of the most tragic, but least known, acts of that historic cataclysm. I doubt, however, if any event he describes is more instructive than the breaking of the September mobs into the Asylum of the Bicetre, and the liberation by them of a moral lunatic. It was announced in Paris that the asylums were unjust prison- houses, wherein were incarcerated many victims of kingly and priestly oppression, under the pretence of insanity. They would liberate these unfortunates. When they ran- sacked the Bicetre, this patient loudly proclaimed that he was sane and a victim of tyranny. The keeper said he a was lunatic without disturbance of intellect, but of very bad passions—but the keeper came near being killed for his unphilosophic remark. The mob released this patriot prisoner, and led him in triumph through the streets. .“The sight of so many armed men, their loud and confused shouts, and their faces flushed with wine, roused the madman’s fury. He seized the sabre of his next neighbor and wounded several of his liberators. 8 Had he not been promptly mastered he would soon have avenged the cause of outraged humanity. The savage mob then thought proper to lead him back to his cell, and with shame and reluctance yielded to the voice of justice and experience.” 1 Pinel described this case as an example of mania without delirium, and subsequent writers who rely upon him have mistaken him, I believe, in considering that he meant a purely emotional insanity. I think he meant a mania without fixed, systematized de- lusions, and if he were here to-night I do not believe that he would say that this madman of the Bicetre had an un- disturbed reason. Dr. Prichard, of England, is usually credited with being the progenitor of the school who teach the doctrine of moral insanity, although Dr. Rush, of Philadelphia, clear- ly indicated the same psychological distinctions. Prich- ard records seventeen cases as illustrative of this class of patients, and as a superstructure can be no more se- cure than the foundation upon which it rests I will briefly call your attention to a very few of these frightful examples. One patient was a literary man who was married to a literary wife, and became so suspicious that the world would say his wife wrote his books that he re- fused to let her know what he was writing; he acquired strange habits, placing everything in a certain order whether in his own or in other people’s rooms. He would run up and down his garden a certain number of times, spitting alternately on one side and the other in regular succession. He spent much time rolling up little pieces of writing-paper, which he used for cleaning his nose. He committed several acts of violence, argued in favor of suicide, and finally drowned himself in a canal. This man evidently had delusions and insane suspicions, and his little foolish tricks are strongly indicative to my mind of failure of brain-power and possibly compiencing dementia; that there was a strong element of melan- 1 Pinel’s treatise, p. 154. 9 cholia beneath the surface of his disease appears evident to me from his committing suicide. Another of these moral lunatics is recorded as having the delusion that all the persons living in the house with him disliked him, and he confessed that he heard whispers of malevolence and abhorrence. This case was evidently one of the worst forms of insanity—the veritable insane demon who harbors delusions of persecution and hears irritating and deriding voices. To call such a man a moral lunatic without affection of his “intellect,” is a use of terms which to me is worse than an error in definition—it is an injustice to humanity. Another case was a sober and industrious farmer, who became wild, excitable, full of schemes and absurd projects; bought cattle and stock for which he had no use, and a carriage which was much more elegant than he was accustomed to; he called on a man in the middle of the night to take him out to sur- vey his farm. This man is reported to have recovered in an asylum, but my diagnosis of his case at this distance is demefitia paralytica with an early remission, which deceived his physicians into the belief that he had recov- ered his lost conscience. This case 1 regard as an im- portant pointer, for it suggests that many of these so- called moral lunatics are simply cases in the early stages of grave forms of insanity, who render themselves con- spicuous by that erratic conduct and change of charac- ter which are early symptoms, and difficult often of in- terpretation. The whole texture of the brain is changed, and that specialized act which has been called ideation is perverted. The sensations received do not fall into a sound and active cerebral machine to be reflected again as con- scious and intelligible acts, but the brain acts are perverted, weakened, and confused in all the relations and affairs of life. This suggests to me the difficulty often of following these abnormal brain-processes. There is no more diffi- cult problem set before the physician than to unravel the complexities of the insane brain. Its suspicions are so varied and its associations so complex, that it seems 10 sometimes as though it might require the prescience and insight of the greatest of poetic or philosophic minds. A patient whom I examined, and who afterward perished in the burning of the Blockley Insane Department, refused to eat because he had cursed the giver of food in his heart, but the connection of his conduct with a concealed delusion was for a long time not apparent. Another pa- tient of the writer tore up her Catholic prayer-book, ap- parently in an unseemly rage of moral imbecility, but when questioned closely acknowledged the delusion that anyone who said the same prayers as she said would de- prive her of a certain mysterious power which she pos- sessed ; and another patient, who had some extravagant religious delusions and a hyperaesthetic conscience, and who, nevertheless, without apparent reason slandered and abused her husband in the most heterodox manner, was at last brought to the confession of the astounding delu- sion that her husband had grown tired of his normal sexual relations with her, and intended to cut another hole in her abdomen in order that he might enjoy a change ! It is to be noted that moral insanity or imbecility is described especially in children, even more than in adults, and this is significant. In children cerebral activity is more concerned about objects which immediately affect themselves, their comfort, amusements, and various grat- ifications. There is, in fact, much of the animal in them. They do not think or reason much about abstract and remote objects, relations and interests which claim the attention of the grown man, and about which the adult lunatic is apt to form his delusions. The child is pleased with a trifle, deeply interested in his animal appetites, and much harassed by discipline. The man is involved in the deadly struggle for existence, and is brought face to face with the anxious problems of fortune, friendship, religion, and destiny. To the deficient intellect of the imbecile child, bent upon self-indulgence, the greatest good and the readiest methods of self-assertion may seem 11 to be obtainable by theft, incendiarism, and insubordina- tion, while in the man the more complex delusions of persecution and religious melancholia fill up the measure of his woe, just as fidelity and worship widened the men- tal horizon of his perfect health. I speak now of those children who are real imbeciles, whose minds, if thor- oughly tested, would show defective brain power, and who are called moral idiots with good intellects because ap- parently their skulls are not as crooked as their conduct. I do not refer to the spurious cases who are occasionally reported, as, for instance, the kleptomaniac whose case is quoted by Bucknill and Tuke, who made bargains with the merchants that for a nominal sum of blackmail he would not steal from them. 1 do not call such a scamp by a Greek scientific word of five syllables, and I fear that his heaven-sent destiny is the county jail. Neither do I refer to such cases as these eminent authors describe in a pa- tient who was a pyromaniac, and was such a bad girl that she resembled a serpent in her movements. “ Her skin,” we are told, “ was also spotted like a common species of snake ! ” It is impossible for me to determine from this whether a spotted skin is a symptom of moral imbecility or whether it is a custom of serpents to set fire to houses, and in the double doubt I. am willing to assign the tale to the other snake-stories of the newspapers. Erotomania is not an insanity at all as described by many writers. Although increase and perversions of the sexual appetite are not uncommon in different forms of mental disease, I have seen several curious cases in which the trouble was entirely intellectual, rather than moral or sexual. A middle-aged buxom woman came one day, bewailing her uncontrollable lust, which she said she had endeavored to gratify with a number of men, although living an apparently happy and virtuous life with her hus- band. She was excitable and emotional as she talked, and easily became confused, almost incoherent, in her language. The longer she talked the greater the num- ber of her paramours became, and the more exaggerated 12 the details of her illicit relations grew. It was soon ap- parent that her self-accusations were delusions, and when questioned closely on the subject she broke down with the statement that her mind was so confused that she did not know whether she told the truth or not. I saw an old lady recently who was weeping constantly, and tell- ing every person she met that she had committed adul- tery with a worthless fellow about town ; but the good woman’s age and appearance were enough to acquit her Lothario. In the Annual Report of the Elmira State Reforma- tory, N. Y., for 1886, there is a most interesting account, by Dr. H. D. Wey, of an experimental class in physical culture. This class was composed of twelve inmates of the institution for the purpose of determining how far their cerebral condition could be improved by frequent baths, calisthenics, and physical culture. They seem to be as nearly moral imbeciles as could be well picked out, and in his admirable description Dr. Wey has taken the pains to give us an analysis of not only their “moral ” but also their “intellectual” acquirements. Their ages were from nineteen to twenty-nine. The moral capital of these twelve men is summed up as follows : One was convicted for assault, five for burglary in the third degree, one for grand larceny in the first degree, three for grand larceny in the second degree, one for rape, and one for attempted rape. The doctor says truly that the offence of such men when against property is usually such as calls for no great amount of ingenuity, but when com- mitted against the person is of an aggravated form and brutish in details, suggesting uncontrolled passion. This experimental class were serving an average sentence of seven and one-half years. Most of them had been in- temperate. Not one had learned a trade. Their en- vironment before their crimes was bad, many having had intemperate parents, and one an insane, and another an epileptic, mother. In physiognomy many in their photo- graphs are typical of the crime class, and in two the re- 13 ceding forehead is almost typical of idiocy. The faces express mental hebetude and moral obliquity. The “ in- tellectual ” capital of these men is summed up as follows : The ignorance of some was so great that they were un- able to tell in what country they lived. They were with- out purpose or ambition, and seemed simply to exist. “ An idea of their mental attainments can be formed when it is said that one could neither read nor write ; one barely do either ; four understood the successive steps necessary to work an example in long division, but could never ob- tain the correct answer; while the balance were wrecked upon the shoals of rudimentary arithmetic from notation to simple division.” It certainly cannot be said that the intellectual status of these men is any better than their moral status. Their whole cerebral activity is very bad. The class of lunatics from whom are recruited most of the criminal insane comprises the patients with elaborate, systematized delusions. These are the monomaniacs, or, as the Germans call them, the cases of original insanity, or Primare Vcrriicktheit. This has sometimes been called the “insanity of character.” Its roots are deep in the very construction of the man’s brain ; he was born with a bad brain, which is bound not to perform properly its function of ideation. It will not elaborate good thought or sound sentiment in whatever environment it is placed and whatever sensations stimulate it to its special reflexes of comparison and action—at least thus we are taught to believe of these congenital fools. Just here is where a fallacy, I think, creeps into the admirable logic of those who have described this class. While it is true, in every sense, that there is a class of men born with poorly con- structed brains, it is not so applicable a truth that they must necessarily be forever in the grip of a fate which holds them all equally irresponsible lunatics. Men are born with every grade of brain-power, from the micro- cephalic idiot to the sage whose cerebral masses weigh sixty ounces. Character is a varying quality, not always strictly in proportion to the amount and quality of a brain, 14 but also in proportion to the character of the environ- ments of that brain. If there is any truth in the doctrine of evolution, or any force in our systems of education, it seems to me to rest upon this truth. Otherwise we are all the most unfortunate fatalists, and, in a literal sense, the sins of our great-grandfathers are visited upon us with- out amendment or expiation possible on our parts. Hence this doctrine of original insanity, while attractive to the ear and eye, bears a fallacy with it if extended too far. Insanity is not a mere peculiarity of character, else this doctrine may extend its long arms until it embraces all the oddities and eccentricities and notions and fallacies and sins of mankind, or until one-half of the human race is caught by this octopus of the extreme school of alienists. Insanity must be conceded to be something more definite than this, especially criminal insanity, wherein arises the question of responsibility under the law. If Erskine’s test of delusion is applicable at all, it is certainly to this class of lunatics, for insane delusion, fixed and logical, is the essence of their disease ; it supplies the motive, usually, of their crimes (whether its connection with the crime can be traced or not); it dominates their lives and perverts all their conceptions of moral, social, and legal relations. Unless such a positive perversion of cerebral activity can be shown it seems very doubtful if these “ primary cranks ” have passed from the borderland of folly and wickedness into the neighboring field of irresponsible lunacy. “No one,” says an old legal writer, “ is of perfectly sound mind but the Deity; ” but while this may be conceded to the pessimist it can never be admitted as a scientific axiom in medical jurisprudence. We must have some secure ground to tread upon, and some certain landmarks when we come to pass judgment upon a man’s mental health and his criminal responsibility, otherwise the decision may be no more admirable than that which declared General Beauregard insane after the first battle of Bull Run be- cause he had lost the fight and yet was seen, playing in an idle manner with a parrot in his tent; or the judgment 15 which proclaimed Edmund Burke, the orator, to be an emotional lunatic because, when they brought him the favorite horse of his dead son, he threw his arm on the animal’s neck and wept. The Philistines could see in this no more than the morbid sentimentalism, of the author of “Tristram Shandy ” when he wept over the agonies of a dying jackass ! The writer cannot but feel, in common with his pro- fession, a prejudice against hard and fast dogmatic tests of insanity. It is in this respect that the physician has all along been apt to part company with the lawyer. This arises in part from the directly opposite positions taken by the two in regard to the case in issue. The physician, searching for disease, may be too apt some- times to construe slight and irrelevant symptoms as indi- cative of what he seeks, while the lawyer, upon the bald assertion of the law that every man is in normal health until he is proved to the contrary, is always too prone to resist anything but the most glaring and unmistakable signs. It thus happens that the medical definition has sometimes been stretched so wide that it includes cases which shock the common-sense of the most intelligent, while the legal tests have been made so narrow and un- scientific that it is difficult to include in them some of the most patent cases of insanity. The test of “ delusion ” is, I believe, in some forms of insanity an applicable one, but it certainly will not include all classes of mental dis- ease, while the test of knowledge of “right and wrong” is founded, I think, upon a misconception of the unity of the brain-function not unlike that which has supplied the doctrine of moral insanity. A scientific diagnosis ought to b * made in court just as in a hospital. 1 believe that the conception, and rigid adherence to the conception, of the cerebrum as an individual unit, whose special act is always a reflex process of ideation, tends to a satisfactory definition and classification of insanity, as well as to an intelligible application of our knowledge to the solution of medico-legal questions, much superior to anything at- 16 tainable by the distinctions of the metaphysicians or the arbitrary tests of the judges. This process of ideation may be depressed or exalted (as in melancholia or mania), it may be perverted (as in monomania), it may be con- fused and incoherent (as in a variety of forms), or it may be utterly disorganized (as in dementia), but I certainly have not yet seen a case of insanity in which it was not in one or the other of these states. Southwest Corner Walnut and Fortieth Streets, Philadelphia, Pa.