Homicidal Insanity, 1800-1985

4. From Static Brain to Dynamic Neurophysiology, 1840-1870

4 From Static Brain to Dynamic Neurophysiology 1840-1870 In 1840 the idea that insanity was disease ofthe brain was the starting point of all psychiatric theory and practice. Yet, the ultimate nature of the brain was subject to intense controversy and philosophical interpretation. Some physicians conceived of it as an aggregate of parts that could become individually or collectively deranged. Others imagined it to be a unitary organ that was never subject to partial pathologies. All agreed, however, that it was subject to irritation from the visceral organs and from moral causes, namely "bad living" and life's misfortunes. Over the next thirty years, the idea that the brain was a static organ that was acted upon from without would change to the conception of the brain as a physiological dynamism. The new alienists would therefore reason that psychiatric patients were unpredictable and more universally dangerous than earlier physicians had believed. Intellectual Insanity; Homicidal Mania and Delusional Insanity Alienists on both sides of the ocean disagreed about the fundamental issue of the power of the intellect to control behavior. For many years into the nineteenth century, the delusion had been the single diagnostic criterion of insanity because alienists and law47 48 Homicidal Insanity, 1800-1985 yers agreed that insanity was by definition derangement of the intellect . By the 1840S such a single criterion had been successfully challenged in theory and in practice, but derangement of the intellectual faculty, evidenced by false ideas, continued to serve as an unamibiguous symptom of insanity. Some alienists believed that any delusion made the patient dangerous, but for the most part, early clinicians had established the standard that it was the content of the delusion rather than the mere fact of its existence that made the patient dangerous. The presence of hallucinations and illusions, though separate phenomena, were generally taken to be closely associated with the existence of delusion. In this context, therefore, homicidal mania or delusional insanity often meant that the patient exhibited delusions , hallucinations, and illusions. Delusional insanity therefore meant that the patient's intellectual faculty was impaired in the broadest sense. The Primacy of Reason In 1844 Brigham interrogated more than twenty criminal lunatics on the subject of "right and wrong" and learned that they showed no defect of reason. He therefore argued that the homicidal impulse was a partial insanity: Their opinions on the subject were correct [that it was wrong to steal and that murder was the greatest crime]; but still, the same individuals may be wholly unable to resist their diseased impulses, and therefore commit crimes they know to be wrong. Other deranged persons commit crimes from delusions, in obedience to supposed commands from others, or from on high; and although they know the act in itself is wrong, they dare not, and cannot disobey the command. I Only the most naive clinicians could ignore cases of homicidal insanity characterized by remorselessness and impulsivity. Those who recognized the existence of such cases but who rejected the concept of partial insanity maintained that intellectual involvement was always present but overlooked. On the issue of behavioral control, Gray said that even in intellectual involvement the To Dynamic Neurophysiology 49 insane rarely lost their self-control, a fact that constituted the basis for moral treatment. He believed that this fact accounted for the observation that they could conceal their delusions. 2 Moral somaticists who rejected separating the faculties of mind nevertheless recognized that one class of symptoms could predominate in insanity. But it followed, they reasoned, that all cases progressed eventually to dementia. They did not believe that the disease could remain stationary for long. At the 1863 meeting of the Association, Andrew McFarland, medical superintendent of the Illinois State Hospital, read a paper on "Minor Mental Maladies ," which stimulated substantial discussion on the issue of intellectual involvement in insanity. Gray, of course, remained unalterably opposed to any form of partial insanity: "Insanity is something more than the perturbed emotions and the loss of selfcontrol ." He then asserted that disturbance of the moral feelings led ultimately to dementia, "the terminal stage of insanity." John Tyler, of the McLean Asylum, challenged him on the question of melancholia: I wish to know whether Dr. Gray has any doubt that the starting point [ofmelancholia] is in the feelings, and not in the perversion ofthought? Dr. Gray: I presume that in melancholia the feelings are the first affected, and that before the intellect...