PART I — часть 5

Heredity varies with the psychoses, having its greatest influence in the transmission of manic-depressive attacks, epileptic and hysterical conditions, nervousness, compulsive and impulsive insanity, sexual perversions and morbid personalities (Kraepelin). As the result of a study of two thousand cases, Pilcz[69] (1907) found that in alcoholism heredity was most likely to manifest itself in the form of alcoholism, epilepsy and imbecility or manic-depressive psychoses. In the progenitors of epileptics he found epilepsy and migraine. Apoplectics showed a family history of paralysis, arteriosclerosis, senile dementia or melancholia. Senile dementia preceded paralysis, arteriosclerosis, feeblemindedness and dementia praecox. Tabes and paralysis apparently frequently precede paralysis and dementia praecox. The various forms of alcoholic psychoses furthermore show a tendency to repeat themselves in the offspring of alcoholics. Similar heredity is said to be the general rule in manic-depressive psychoses, epilepsy and alcoholism, and to a less extent in arteriosclerosis. Heredity, in so far as it is related to mental diseases, may be said to be largely a question of the transmission of a neuropathic or psychopathic constitution or predisposition. Various psychoses are now held to be the direct result of constitutional causes or hereditary influences. This is probably true of manic-depressive insanity, Huntington's chorea, involution melancholia, dementia praecox, paranoia and paranoid conditions, epileptic psychoses, the psychoneuroses and neuroses, psychopathic personality and mental deficiency. It is true that some of these conditions develop as the immediate results of certain predisposing factors and that in frequent instances no evidences of heredity can be found. It is also true that various authorities maintain that a predisposition to the development of certain psychoses may be acquired. If, however, we assume that the above mentioned psychoses are constitutional in their nature and due primarily to heredity, it may be definitely stated that, based on recent statistical studies, hereditary influences account for from fifty-five to sixty per cent of the mental cases admitted to our institutions. It may be pointed out, as an objection to this suggestion, that although manic-depressive psychoses often develop in an emotionally unstable or cyclothymic personality and dementia praecox is associated with certain peculiarities of makeup, not all of these cases show clear evidences of constitutional origins. This is unquestionably true. It is equally true, on the other hand, that heredity is also probably very often a factor in the production of the senile and arteriosclerotic conditions, various nervous diseases, alcoholism and drug habits.

When we leave the subject of heredity we are on much more certain ground. There is no question whatever as to the rôle played by traumatism, senility, arteriosclerosis, syphilis, brain and nervous diseases, alcoholism, exogenous toxins, epilepsy, pellagra and somatic diseases in the causation of mental disorders. In an analysis of 4,079 cases examined at the Munich Clinic, Kraepelin[70] found the following factors involved:—1. Physical diseases, infections and gross brain lesions, 1.3 per cent; 2. Syphilis and metasyphilis, 10.3 per cent (general paresis 9.4 per cent); 3. Toxins—alcohol, morphine, cocaine, etc., 22.8 per cent (alcoholic psychoses 22.4 per cent); 4. Traumatic neuroses and prison psychoses, 2.5 per cent; 5. The presenile and senile psychoses, arteriosclerosis, etc., 5.6 per cent; 6. Dementia praecox, epilepsy, idiocy and imbecility, 27.2 per cent; 7. Psychopathic and hysterical states, and manic-depressive insanity, 30.3 per cent. Conditions existing in our hospitals and clinics are somewhat different. As the result of a study of over seventy thousand first admissions to forty-eight hospitals in sixteen different states we are now in a position to speak quite definitely as to the frequency of the conditions above referred to as etiological factors. Traumatic psychoses quite uniformly represent a little less than one-half of one per cent of the admissions to our institutions. The senile psychoses constitute approximately ten per cent and arteriosclerosis five per cent of the total. General paresis averages about twelve per cent in the New York hospitals and from seven to ten per cent in the other states. Cerebral syphilis amounts to a little less than one per cent of the cases. It should be said that in the large cities the rate for syphilis is, in some instances at least, twice as high as that given. Brain tumor, with all other brain and nervous diseases, only constitutes about one and one-half per cent of our admissions. Alcoholism, which has been responsible for as high as ten per cent of all admissions, from time to time, has been decreasing gradually during the last five years and in New York in 1920 constituted less than two per cent. Epileptic psychoses in our state hospitals amount to from one to two and one-half per cent of the total. As a general rule pellagra is not a factor of any consequence, amounting to less than one-half of one per cent of the admissions. In a few of the southern hospitals large numbers of pellagra are encountered. The psychoses accompanying somatic diseases are represented by from three to four per cent of the whole number. In addition to this, there is still a considerable number of cases reported from the hospitals as being caused by psychic trauma of various kinds. These represent the acute psychoses usually resulting from mental and emotional upsets but with nothing which definitely points to constitutional disorders or hereditary influences.

If we speak of predisposing causes, some reference should be made to the influence of the physiological landmarks which are of so much significance in the life of the individual in more ways than one—puberty, adolescence, the climacterium and the senium. A no less noteworthy factor in the female sex is the puerperium. These periods of life are of tremendous importance in the development of the psychoses. It is customary to speak of age, sex, race, civil condition, degree of education, climate, civilization, etc., as factors in the production of mental diseases. Not much is to be said on these questions, nor are they closely related to the subject. On January 1, 1920, there were 232,680 patients in the hospitals for mental diseases in the United States. Fifty-two per cent of these were men and forty-eight per cent women. This represents about the difference that has been shown for many years. The reduction in alcoholic psychoses may affect this ultimately. The striking exceptions to this ratio are Massachusetts and New York, where the number of women has slightly exceeded the men for a number of years. The admission rate for men is, however, slightly higher than that for women in both of those states. Less than one-half of one per cent of the patients admitted to the New York hospitals are under fifteen years of age. In that state approximately five per cent have been between fifteen and nineteen years old. In Massachusetts the percentage of persons admitted who were under twenty years of age has averaged 8.5 quite consistently for some time. The admission rate, for twenty to twenty-five, twenty-five to thirty, thirty to thirty-five and thirty-five to forty years of age in Massachusetts and New York has averaged from ten to eleven per cent for each of those periods for several years. From the age of forty to fifty the admission rate is about 8.5 per cent, and from fifty to sixty between five and six per cent. Nine per cent of the admissions in Massachusetts and eight per cent in New York are seventy years of age or over. The statistics on race, birthplace and the psychoses of the various races are shown in detail in the chapter on Immigration. The admission rate in New York is almost exactly the same for the married and the unmarried, the former constituting about thirty-nine per cent and the latter forty. In Massachusetts the single first admissions amount to about forty-three per cent and the married approximately forty per cent. Throughout the country generally the unmarried slightly predominate. The percentage of widowed in Massachusetts and New York varies from thirteen to fourteen per cent. The divorced constitute only about one per cent of all admissions. As to education, it may be said that about nine per cent of all first admissions are illiterate, from fifteen to twenty per cent can read and write only, about sixty per cent have had a high school and two per cent a college education. A study of economic conditions shows that from fifteen to seventeen per cent are dependent, from sixty to seventy per cent are rated as marginal, and from eleven to thirteen per cent as being in comfortable circumstances. In Massachusetts and New York about eighty-five per cent of the admissions come from a city environment and from twelve to fifteen per cent from rural communities. It is interesting to note that in 1919 eighteen per cent of the admissions in Massachusetts and New York were reported as being intemperate in their habits, with over fifty per cent abstinent.

In conclusion, it may be said that the important etiological factors in the production of mental disease are heredity, senility, syphilis, arteriosclerosis, somatic diseases, mental deficiency, epilepsy, diseases of the brain and nervous system, alcoholism, drugs, traumatism and mental stress and shocks of various kinds. It is hardly necessary to add that our information on this subject is far from complete.

CHAPTER IX

IMMIGRATION AND MENTAL DISEASES

A history of the development of our western civilization is very largely a study of the process of assimilation of the various racial elements representing a new population. While it must be conceded that we are indebted to European countries for much that has been contributory to the welfare and success of American institutions, it is equally true that the tremendous increase in mental diseases and defects here is to be attributed in no small degree to immigration. This constitutes a problem of social and economic importance which is worthy of serious consideration. Perhaps no better evidence of this fact can be offered than a study of such statistics as are available relating to the thirty-three millions of people coming to the United States from other countries during the last century. This would seem to be particularly indicated at this time, in view of the fact that the conclusion of the war has brought about the necessity of a new adjustment of our relations with other countries.

Immigration to the United States has varied greatly from time to time. It is a well known fact that the founders of our government were practically all of English, Dutch, German or Scotch-Irish extraction. Unfortunately no information of any consequence is available regarding the aliens entering the country prior to 1820, when their study was first undertaken by the federal authorities. As far as can be determined, during the ensuing ten years about 128,000 were admitted at the various ports of entry. The history of immigration since that time has been determined very largely by existing conditions in other countries. The famines and political disturbances in Ireland between 1840 and 1850 were the occasion of a large influx, concededly of a highly desirable type. The nature of the tide of incoming immigrants was changed by the revolutionary troubles in Germany during the decade following 1848. There was a decrease for a time during the civil war. This was soon followed by a considerable increase which continued quite consistently until the outbreak of the world war. There would at this time seem to be every reason for thinking that an unprecedented invasion can be expected during the next twenty-five years as a result of conditions prevailing abroad unless some restrictions are imposed. In 1850 and 1860 the number of Irish people in the United States exceeded the German born. The 1890 census showed a predominance of the latter race and they have exceeded the Irish element in the population for some time. Nearly a million Germans were admitted between 1880 and 1885. Since 1890, however, the number of Irish and Germans entering have both decreased markedly. After the Spanish-American war a great increase in immigration was noted and the rate of admission per year reached a million in 1905, but the source of supply had entirely changed.

Salmon[71] has shown that in spite of the fact that in 1882 only 12.9 per cent of all incoming aliens admitted were from those countries, eighty-one per cent of all immigration from Europe in 1907 came from Austria-Hungary, Bulgaria, Greece, Italy, Montenegro, Poland, Portugal, Roumania, Russia, Servia, Syria and Turkey. In 1882, 87.1 per cent of those admitted came from England, Germany, Holland, Norway, Sweden, Switzerland and Belgium. The races represented by the new tide of immigration, according to Salmon, were Slavic, thirty per cent, Italian, twenty-six per cent, and Hebrew, fifteen per cent, the remainder being made up of various other miscellaneous elements. This change is shown by the fact that the immigration from Austria-Hungary, which amounted to only 711,926 from 1820 to 1896, increased to 2,303,323 during the first decade of the present century. Five hundred and thirty-four thousand three hundred and thirty-six were admitted from Russia between 1820 and 1896 and 1,756,027 between 1900 and 1911. The Italian immigration, which amounted to 676,826 between 1820 and 1896, increased to 2,228,759 between 1901 and 1911 (Salmon[72]). The numerical status of immigration by decades is shown in the following table:

A study made by the United States Immigration Commission some years ago showed that of 68,942 foreign born males employed in various mining and manufacturing industries, and who had been in the United States for five years or more, only 33.3 per cent had obtained naturalization papers. Of 246,673 of this same class representing non-English speaking races, only 53.2 per cent had learned the language of this country to any extent. A report made by the Commissioner General of Immigration showed that of 719,906 immigrants over fourteen years of age and admitted from 1899 to 1909, 26.6 per cent could neither read nor write and 29.8 per cent had no occupation. The following table shows the percentage of foreign born in the population of the United States from time to time as stated in official reports:—

The foreign born population naturally varies more or less in different parts of the country. In New York state it was twenty-six per cent in 1870, 23.8 in 1880, 26.2 in 1890, 26.1 in 1900, 29.9 in 1910, and 26.8 per cent in 1920. In Massachusetts it was 30.6 per cent in 1895, 30.2 in 1900, 30.3 in 1905, 31.5 in 1910, 31.2 in 1915, and 28 per cent in 1920.

We have little authentic information relative to the institution population prior to 1903. The United States Census Bureau in its report of 1904 on the insane in hospitals shows that in 1903 there were 140,312 patients, of which number 47,078, or 34.3 per cent, were of foreign birth. The percentage of foreign born in state hospitals in various parts of the country at that time were as follows:—

In 1912 an investigation was made of the foreign born in the New York state hospitals. As a result of the census taken, it was found that of 31,624 patients, 13,728, or 43.4 per cent, were foreign born. Of this number 4,487 had been naturalized and 9,241, or 29.2 per cent of the total hospital population were aliens. At the Manhattan State Hospital in New York City, out of a total of 4,570 patients 2,526 were foreign born and only 708 had been naturalized. The Central Islip State Hospital at the same time had 4,438 patients. Of this number 2,803 were foreign born and only 891 were naturalized citizens. Thus, at the Manhattan State Hospital 39.8 per cent and at the Central Islip State Hospital 43.1 per cent of the patients were aliens. It was shown that the average hospital residence of the insane in the state was 9.85 years. Based on the maintenance expenditures for 1912 it was estimated that the cost to New York for caring for its 9,241 aliens in the state hospitals was $2,579,902.78 per year, and for their entire hospital residence, over twenty-five million dollars.[73] Of the first admissions to the New York hospitals for the eight years beginning October 1, 1904, and ending September 30, 1910, 46.2 per cent were foreign born. The citizenship of the first admissions for this same period is shown by the following table:—

It was also shown that 14.7 per cent of the aliens admitted in 1905 had been in the United States less than three years, in 1906, 18.7, in 1907, 21.8, in 1908, 20.1, in 1909, 18.1, in 1910, 15.5, in 1911, 14.9 and in 1912, 18.1 per cent. The birthplace and citizenship of first admissions to the New York state hospitals since 1912 is shown in the following table:—

The percentage of the foreign born as shown by the first admissions to the Massachusetts state hospitals during the last eleven years was as follows:—

The percentage of aliens as shown by the first admissions to Massachusetts hospitals was 26.40 per cent in 1918, 27.54 in 1919 and 22.73 per cent in 1920.

Studies of the population of the New York state hospitals show that the aliens have for a period of several years constituted nearly thirty per cent of the entire number. The influence which immigration may have had in determining the relative frequency of various psychoses in our institutions is an exceedingly interesting question. In speaking of the susceptibility of certain races to special types of disease, Salmon[74] says, "This is particularly true of mental diseases, for if racial characteristics profoundly affect political, social and religious ideals we must look for a similar influence upon the individual makeup which so largely determines trends in mental disease. All those who are familiar with mental diseases among the Japanese in California testify to the remarkable tendency to suicide in that race, not only in depressed conditions but in conditions in which suicidal tendencies, in other races, are not frequent. This is in accordance with the general attitude of the Japanese toward self-destruction. The strong tendency to delusional trends of a persecutory nature in West Indian negroes, the frequency with which we find hidden sexual complexes among the Hebrews and the remarkable prevalence of mutism among Poles, even in psychoses in which mutism is not a common symptom, are familiar examples of the influence of racial traits upon mental diseases." As the result of a special study of this subject Salmon has reached the following conclusions: "1. The psychoses more prevalent among Hebrews than in the native stock are manic depressive psychosis, dementia praecox, the psychoneuroses, and psychoses associated with constitutional inferiority. 2. The absence of alcoholic psychoses among Hebrews is the most striking clinical fact in connection with immigration. In 1909 there were but 3 patients with alcoholic psychoses in 448 Hebrews admitted to all the New York state hospitals. 3. The very high prevalence of general paresis among Italians bears a direct relation to the high prevalence of venereal diseases among Italians in New York.... 4. Italians show a freedom from alcoholic psychoses second only to Hebrews. 5. Italians exceed the native born in the prevalence of epileptic psychoses, infective exhaustive psychoses and dementia praecox.... 7. From the data available, alcoholic psychoses are found to be more prevalent among Slavs than among any other races of the new immigration, but not as prevalent as among the native-born. 8. General paresis is nearly twice as prevalent among Slavs as in the native-born, but not so prevalent as among the Italians. Dementia praecox is more prevalent among the Slavs than among the native-born."

The racial representation as shown by statistics of first admissions is fairly constant in New York state, at least, as is shown by the following table of percentages:—

The 1916 report of the Commission on Mental Diseases shows the following analysis of the nativity of the 34,300 first admissions to the Massachusetts state hospitals covering a period of thirteen years (1904-1916):—

It should be borne in mind that these statistics represent birthplace and not race. An analysis of the above figures shows that 54.68 per cent were born in the United States and 44.42 per cent in other countries. Of the other countries represented, 3.96 per cent were born in England, 3.32 per cent in Russia, 9.63 in Canada and 14.67 per cent in Ireland.

A comparison of the more important psychoses represented by the various races, as reported by the New York State Hospital Commission in 1918, is shown in the following table[75]:—

Some variation is shown by a similar analysis of the New York admissions for the year 1919, as is illustrated by the following table[76]:—

For purposes of comparison an analysis of the psychoses shown by various races in the admissions of the Massachusetts state hospitals for a period of three years is added (1917-1918-1919):—

This shows some very interesting results. It will be noted that the Hebrews and Italians have the highest rate for dementia praecox, the percentage shown by these races being much higher than any of the others. The Germans, Italians and Hebrews, in the order mentioned, have the highest rates for manic-depressive psychoses. The frequency of alcoholic psychoses as shown by the Irish is nearly double that of any of the others. The Slavonic race has the highest rate for general paresis, followed in close succession by the French and Germans. The highest rate for senile and arteriosclerotic psychoses combined is shown by the races of mixed origin, the next highest by the English, closely followed by the Irish. The most common psychosis in every instance is dementia praecox. In the admissions to the institutions for the criminal insane in New York the highest percentages are represented by the Irish, Italian and Hebrew races, as shown in another chapter. During a period of six years (1912 to 1918) a study of first admissions to the New York state hospitals shows an incidence of dementia praecox in the native-born of 75.2 per hundred thousand of the population and in the foreign born of 161.4. The importance of this is shown by the fact that over fifty per cent of the entire hospital population is made up of cases of dementia praecox.

The necessity of some supervision of immigration for the purpose of preventing the entrance of undesirable aliens has long been recognized. As early as 1824 the state of New York tried by legislation to prevent the admission of the insane and mental defectives. This effort was a failure, probably owing to the fact that the proposed enactments would have compelled the companies responsible for the entrance of undesirable aliens to remove them if they became a public charge. The introduction of discordant racial elements from abroad at one time disturbed the equilibrium of the entire country. The agitation for the restriction of immigration before the civil war led to the formation of a political organization known as the "Native American" or "Know Nothing" party, as it was usually called. It at one time had forty representatives in Congress and nominated a candidate for President in 1856. These disturbed conditions led to the consideration of this subject by Congress as early as 1838 and the Judiciary Committee recommended legislation prohibiting the entrance of idiots, lunatics and those suffering from incurable diseases or convicted of crime. The action of several foreign countries in pardoning murderers with the provision that they should emigrate to the United States led to a resolution of protest by Congress in 1860 and shortly thereafter a statute intended to encourage immigration was repealed. An investigation made by the United States Immigration Commission brought to light the fact that the great influx of foreigners was largely caused by the agents of the steamboat companies abroad and that they had "five or six thousand ticket agents in Galicia alone."[77]

The activities of those opposed to the indiscriminate entrance of objectionable aliens led to the federal enactment of August 3, 1882. The Secretary of the Treasury was charged with the duty of prohibiting the landing of lunatics, idiots and persons liable to become a public charge. The provisions for the execution of this law were not satisfactory and it was amended by an act of 1891. This made it a misdemeanor to bring in any of the above proscribed classes and imposed a fine of over one thousand dollars upon anyone guilty of so doing. Section 11 provided that aliens entering in violation of this law could be returned at any time within one year thereafter at the expense of the person or persons, vessel, transportation company or corporation responsible for their entry, and further, that those becoming public charges within one year from causes existing prior to landing should be considered as having entered in violation of law. The provisions of this statute were unchanged until the act of March 3, 1903. This excluded persons insane within five years previous to landing, those having had two or more previous attacks at any time, paupers and all others liable to become a public charge. Section 17 delegated to the officers of the United States Public Health Service the duty of determining the condition of all immigrants. Section 20 provided that aliens coming to the United States in violation of law, or who were found to be public charges from causes existing prior to landing, could be deported at any time within two years. Section 21 authorized the Secretary of Commerce and Labor to deport any alien within three years of entering in violation of the act.

An important step in the legislative restriction of immigration was the amendment of Feb. 20, 1907. This made mandatory the exclusion of idiots, imbeciles, the feebleminded, epileptics, insane, all who had been insane within five years and persons having had two or more attacks of insanity at any time, or who were likely to become a public charge, as well as individuals not comprehended in the foregoing excluded classes but found to be suffering from mental or physical defects of such a nature as to affect their ability to earn a living. Section 20 provided that an alien entering in violation of law or becoming a public charge from causes existing prior to landing should, upon the warrant of the Secretary of Commerce and Labor, be taken into custody and deported to the country from whence he came at any time within three years after the date of his entry into the United States. The cost of this removal was to be a charge upon the owners of the vessel or transportation line immediately responsible. When the mental or physical condition of the alien was such as to require personal care or attention, the Secretary of Commerce and Labor was authorized to employ a suitable person for that purpose. This was a great step in advance. There were, however, some very great difficulties to be overcome. The force placed at the disposal of the Public Health Service for the inspection and examination of incoming immigrants was entirely inadequate and one or two men were sometimes responsible for the examination of several thousands aliens in a day. This was, of course, impossible. The burden of proof in showing that the mental condition was due to causes existing prior to landing, furthermore, devolved upon the persons requesting deportation. It was impossible in many instances to submit actual proof even where there could be no reasonable doubt as to the facts. This led to great difficulties and much dissatisfaction. Another serious objection to the provisions of this law was the requirement that only such persons could be deported as were likely to become a public charge. In many instances such persons were supported by private funds until they were no longer deportable, after which they became a burden upon the state in which they resided.

These conditions were much improved by the action of the Sixty-fourth Congress in 1917. This definitely excluded "all idiots, imbeciles, feebleminded persons, epileptics, insane persons; persons who have had one or more attacks of insanity at any time previously; persons of constitutional psychopathic inferiority," etc., or "persons not comprehended within any of the foregoing excluded classes who are found to be and are certified by the examining surgeons as being mentally or physically defective" or persons likely to become a public charge. Section 9 provided that it shall be unlawful for any person, "including any transportation company," to bring either from a foreign country or any insular possession of the United States any alien afflicted with idiocy, insanity, imbecility, feeblemindedness, epilepsy, constitutional psychopathic inferiority, etc., and subjected to a fine any person or persons so doing. The Secretary of Labor was also authorized to detail inspectors and matrons to duty on vessels carrying immigrants, who shall "report to the immigration authorities in charge at the port of landing any information of value in determining the admissibility of such passengers that may have become known to them during the voyage." It also provided that a mental examination of all arriving aliens should be made by medical officers of the United States Public Health Service who shall certify all mental defects or diseases observed. "Medical officers of the United States Public Health Service who have had special training in the diagnosis of insanity and mental defects shall be detailed for duty or employed at all ports of entry designated by the Secretary of Labor." Section 19 provided, that any alien "who within five years after entry becomes a public charge from causes not affirmatively shown to have arisen subsequent to landing" shall, upon warrant of the Secretary of Labor, be taken into custody and deported. The act also made provision for the first time for a literacy test which has been a subject of discussion for years. These amendments are of far-reaching importance and will eventually undoubtedly afford the hospitals considerable relief. The fact still remains, however, that the individual states are expending millions of dollars annually for the care and maintenance of an alien population which should have been excluded by the federal government. Under these circumstances it would seem nothing more than fair that the states should be reimbursed for the cost of carrying a burden for which they are in no way responsible.

CHAPTER X

MENTAL DISEASES AND CRIMINAL RESPONSIBILITY

The question of responsibility for criminal acts, once a legal problem pure and simple, is now recognized as involving sociological, psychological and psychiatric considerations of far-reaching importance. This viewpoint, none too thoroughly established even now, represents the progress of several centuries, and still lacks adequate recognition in law. The eloquent protest against the legal conception of mental diseases written by Isaac Ray[78] in 1838 sounds like a quotation from a recent medical journal. "In all civilized communities, ancient or modern, insanity has been regarded as exempting from the punishment of crime, and vitiating the civil acts of those who are affected with it. The only difficulty, or diversity of opinion, consists in determining who are really insane, in the meaning of the law, which has been content with merely laying down some general principles, and leaving their application to the discretion of the judicial authorities.... It is to be feared, that the principles, laid down on this subject by legal authorities, have received too much of that reverence which is naturally felt for the opinions and practices of our ancestors; and that innovations have been too much regarded, rather as the offspring of new-fangled theories, than of the steady development of medical science. In their zeal to uphold the wisdom of the past, from the fancied desecrations of reformers and theorists, the ministers of the law seem to have forgotten, that, in respect to this subject, the real dignity and respectability of their profession is better upheld, by yielding to the improvements of the times, and thankfully receiving the truth from whatever quarter it may come, than by turning away with blind obstinacy from everything that conflicts with long established maxims and decisions."

A brief reference to the history of the development of the present legal conceptions of criminal responsibility will justify the comments made by Ray. The terms idiocy, lunacy and non compos mentis were all used by Coke in his "Institutes of the Laws of England" written, as nearly as can be determined, in 1625. A differentiation between the significance of the word idiot and non compos mentis appeared as early as 1325 in the English statute "De Praerogativa Regis," which delegated various responsibilities to the crown that are recognized to this day. Sir Matthew Hale, about 1670, described a partial and a total insanity, the former not being accepted as relieving the accused of responsibility for the commitment of a crime. It is an interesting fact that we still hear the question of partial insanity seriously discussed. In 1723 Justice Tracy in a murder trial ruled that "a prisoner in order to be acquitted on the ground of insanity must be a man that is totally deprived of his understanding and memory, and doth not know what he is doing no more than an infant, than a brute or a wild beast." As a result of this ruling a man was found guilty of attempting to murder a neighbor who sent devils and imps into his house at night for the purpose of disturbing his sleep. Fortunately the sentence was commuted to life imprisonment. In 1812 the Attorney General of England[79] ruled that "a man may be deranged in his mind—his intellect may be insufficient for enabling him to conduct the common affairs of life, such as disposing of his property, or judging of the claims which his respective relations have upon him; and if he be so, the administration of the country will take his affairs into their management, and appoint to him trustees; but, at the same time, such a man is not discharged from his responsibility for criminal acts."

The legal procedure of the present day is based very largely on the decisions made at the time of the McNaughton trial in 1843. In this case the Chief Justice, as quoted by Lord Lyndhurst, addressed the following words to the jury: "The point which at last will be submitted to you will be whether or not on the whole of the evidence you have heard you are satisfied that at the time the act was committed, for the commission of which the prisoner stands charged, he had not that competent use of his understanding as not to know what he was doing with respect to the act itself—a wicked and wrong thing—whether he knew it was a wicked and a wrong thing he had done, or that he was not sensible at the time he committed this act that it was contrary to the laws of God and man." This case led to a very serious consideration of the subject in the House of Lords. As the result of an official request for an opinion, the majority of the judges of the court, all concurring but one, expressed the view that "to establish a defense on the ground of insanity, it must be clearly proved that at the time of the committing of the act the accused party was labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing; or if he did know it (sic) that he did not know he was doing what was wrong."[80]

The importance and significance of these decisions, which one might very readily assume to be obsolete and too ancient to be worthy of consideration, will be made clear by a quotation from the penal code in effect in New York today. "Sec. 1120 (Penal Law). Incompetency of idiot or lunatic. An act done by a person who is an idiot, imbecile, lunatic or insane is not a crime. A person cannot be tried, sentenced to any punishment or punished for a crime while he is in a state of idiocy, imbecility, lunacy or insanity so as to be incapable of understanding the proceeding or making his defense. A person is not excused from criminal liability as an idiot, imbecile, lunatic or insane person except upon proof that, at the time of committing the alleged insane act, he was laboring under such a defect of reason as 1, not to know the nature and quality of the act he was doing; or 2, not to know that the act was wrong." It will, I think, be conceded that we have, at least, not lost ground in any way since 1843.

No less interesting is the legal definition of insanity in Massachusetts: "The words 'insane person' and 'lunatic' shall include every idiot, non compos, lunatic and insane and distracted person." (Chapter 4, Sec. 7, General Laws of Massachusetts.) In New York the terms lunatic and lunacy include every kind of unsoundness of mind except idiocy. (Chapter 22, Sec. 28, Consolidated Laws.) This would presumably include psychopathic personality and imbecility.

Numerous court decisions have had a material bearing on the subject of responsibility. It has been held in New York that partial or incipient insanity is not a sufficient defense if there is still an ability to form a correct perception of the legal quality of the act and to know that it was wrong. (People vs. Taylor, 138 N. Y. 398, 407 (1893)). A weak or disordered mind is not excused from the consequences of crime. (People vs. Burgess, 153 N. Y. 561, 569 (1897)), etc. Generally speaking, the legal methods of determining criminal responsibility do not vary to any material extent with the different states. It is obvious that the responsibility for crime as defined by the courts is far from harmonizing with the conception of competency entertained by the medical profession. To the psychiatrist, if the criminal act is the result of the mental condition it constitutes a symptom of the disease process. It is readily apparent from even a very brief reference to the statutes that a person concededly suffering from paranoia, general paresis, dementia praecox or any other well-defined psychosis is still criminally liable for his insane acts within certain limitations. From a medical point of view the existence of a psychosis, if associated with a consequent judgment defect, emotional instability, disturbance of volition, intellectual deterioration, delusional and particularly persecutory control, hallucinatory trends, ideas of reference, etc., is of itself quite sufficient to explain criminal acts in the insane. This, however, as has been shown, is not the legal point of view. The accused is fully responsible unless it can be shown that he is suffering from such a defect of reason as not to appreciate the quality or nature of his act or that the act is wrong. There is no other legal standard. It is a well-known fact that many persons adjudged insane by the courts and committed to our institutions are fully competent to discriminate between right and wrong from an ethical point of view, although legally held to be incompetent and unsafe to be at large. These divergent viewpoints presumably are due to the fact that the law moves only with a degree of dignity which theoretically guarantees absolute security in avoiding any possible sources of error. It nevertheless is responsible for many miscarriages of justice.

Efforts to remedy this state of affairs have been made repeatedly by the medical profession. The American Psychiatric Association has devoted a great deal of time and attention to this subject, unfortunately without any very concrete results. The last official action taken was the unanimous approval of the following resolutions:— [81]

"Resolved: 1. That the proved rarity of wrong acquittals on the ground of insanity is the strongest evidence that the abuse of the insanity plea in criminal cases has been unwarrantably exaggerated.

"2. That the insanity plea is not by any means raised as often as it should be, to prevent the frequent miscarriage of justice arising from the conviction and imprisonment of insane persons whose true mental condition has not been recognized.

"3. That the abuses which have crept into the method of presenting medical expert testimony have been largely the result of established legal tests and procedures, although their correction does not require radical change in the laws.

"4. That inaccessibility of the evidence on both sides of the case is the chief cause of defective medical testimony.

"5. That whenever possible the medical witness should not testify unless he has had an opportunity to make both a mental and a physical examination of the person in whose behalf the plea of insanity is raised.

"6. That we consider the hypothetical question as ordinarily presented to be unscientific, misleading and dangerous to medical repute and that the evidence on both sides should always be included in its presentation to medical witnesses.

"7. That in all criminal cases absolutely equal rights should be accorded the medical witnesses for both the prosecution and the defence for the examination of the person alleged to be insane.

"8. That in our judgment the judiciary should by legal enactment be allowed more latitude in enlightening the jury and enabling it to comprehend the nature and meaning of the medical testimony laid before it.

"9. That we recommend as advisable the adoption wherever possible of the so-called Leed's method of preliminary consultation by medical witnesses on both sides of the case as to its status.

"10. That we advocate a freer use of appointments of commissions by the court.

"11. That a period of hospital observation of all persons committing crimes in whose defence the plea of insanity has been raised is by far the best method yet devised for securing impartial and accurate opinions, silencing popular clamor, avoiding prolonged and sensational trials and saving expense to the State; also that we advocate the enactment in every State of laws similar to those of Maine, New Hampshire, Vermont and Massachusetts, providing that such persons may be committed by the court to a State hospital for the insane there to remain for such time as the court may direct pending the determination of their insanity.

"12. That it is the sense of the Association that it is subversive of the dignity of the medical profession for any of its members to occupy the position of medical advisory counsel in open court and at the same time to act as expert witness in a medico-legal case.

"13. That we regard the acceptance by a physician of a fee that is contingent upon the result of a medico-legal case as not in accordance with medical ethics and derogatory to the good repute of the profession, and advocate the regulation of the practice by legislation.

"14. That we are in favor of any legislation that will secure a definite standard of qualification for medical men giving expert testimony."

An equal amount of consideration has been given to this important question from time to time by the American Institute of Criminal Law and Criminology. At a recent meeting of that organization the following recommendations were submitted by a committee:

"1. That in all cases of felony or misdemeanor punishable by a prison sentence the question of responsibility be not submitted to the jury, which will thus be called upon to determine only that the offense was committed by the defendant.

"2. That the disposition and treatment (including punishment) of all such misdemeanants and felons, i.e., the sentence imposed, be based upon a study of the individual offender by properly qualified and impartial experts cooperating with the courts.

"3. That provisions be made permitting the transfer of such misdemeanants and felons at any time after conviction from one institution to another affording a different kind of treatment upon the presentation of evidence of the needs for such action satisfactory to the court which passed sentence.

"4. That no maximum term be set to any sentence.

"5. That no parole or probation be granted without suitable psychiatric examination.

"6. That in considering applications for pardons and commutation careful attention be given to reports of qualified experts showing the applicant's mental age and mental stability and that in drafting statutes determining or defining juvenile delinquency, mental age and mental stability, within reasonable limits, be regarded as of importance with the calendar age of the delinquent.

"In view of the foregoing and as an initial step towards the ends stated, the committee submits the following resolution and urges its immediate adoption:

"Resolved, That the several states be urged to make provision for the psychiatric examination, under conditions permitting prolonged observation when necessary, of all persons convicted of a felony, misdemeanor or other offense by properly qualified experts appointed to assist the court in reaching a decision as to the proper disposition and treatment of the offender."

The courts, the medical profession and the public have shown indications of a decided dissatisfaction with existing methods of determining criminal responsibility. This will certainly continue as long as the sole test of competency is the power of the accused to discriminate between a knowledge of right and wrong at the time when the act is committed. The conditions which lead to crime have been made the subject of scientific study by many. One of the early investigators in this field was Morel, who saw in the criminal a personification "of the various degenerations of the species." Much has been said of "moral insanity," a condition referred to by Abercromby as one "in which all the upright sentiments are eliminated while the intelligence presents no disorders." Lombroso advanced the theory that criminality is a form of atavism—a reversion of man to the primitive and savage type represented by his early ancestors. This theory was based on a careful study of the anatomical, physiological and psychological characteristics of primitive man. His classification included the occasional, the emotional, the born criminal, the moral insane, and the masked epileptic. Marro offered an anatomical basis for the degenerative theory in the form of nutritional defects in the central nervous system. Ferri distinguished between criminal lunatics and emotional criminals and held crime to be "a phenomenon of complex origin and the result of biological, physical and social conditions." "Habitual criminals," he says, "are the victims of a clear, evident and common mental alienation which causes the criminal activity," while the occasional offenders are to be explained by "the impulse of opportunities more than the innate tendency that determines the crime." The emotional criminal, according to Ferri, is a sane and moral individual overcome by momentary emotional paroxysms referred to as a "psychologic storm." Garofalo, on the other hand, looked upon crime as "an offense against the fundamental altruistic sentiments of pity and probity." From his point of view a criminal act was an indication of the loss of a proper sense of appreciation of the life or property of another—a moral anomaly. The Italian school of criminology was responsible also for the theory that criminal acts are only the expression of epileptic symptoms. Sociological workers have attributed crime to influences which overcome the natural resistance of the individual, a variation from which is merely an inability of the person to conform to the laws of environment. Max Nordau sees in human failings only an abnormality which he describes as "human parasitism." Others look upon crime as the natural product of a modern social and economic system. Colajanni ascribes alcoholism, vagrancy and prostitution to poverty, but crime, he says, is "due to necessity and to the degree and kind of education received." In the light of our present knowledge the conclusion would appear to be warranted that crime is the result of constitutional defects in the form of hereditary tendencies and arrested mental development, educational defects, a deterioration of habits as shown by alcoholism, etc., accidental influences such as environment and poverty, pathological conditions, including epilepsy and insanity, and precipitating factors in the form of emotional disturbances.

Criminality, alcoholism, poverty, prostitution and mental deficiency are closely correlated. A special committee appointed by the New York State Prison Commission has made an exceedingly interesting report[82] on the relation existing between mental disease and crime. Their investigation shows that 21.8 per cent of 608 cases at Sing Sing, thirty-five per cent of 459 men at Auburn, twenty-two per cent of three hundred men at the Massachusetts State Prison, twenty-eight per cent of forty-nine women at Joliet, twenty-five per cent of seventy-six women at Auburn, twenty-three per cent of one hundred cases at the Indiana State Prison and thirty per cent of 150 examined at San Quentin were found to be mentally defective. An average of 27.5 per cent has been found in the prison population as a whole. Thirty-one and four-tenths per cent of the inmates of reformatories, training schools, workhouses and penitentiaries were found to be feebleminded. From twenty-seven to twenty-nine per cent of the inmates of penal and correctional institutions of the country were said to be defective. About thirty per cent of the population of the penal institutions for women in New York were found to be feebleminded. A study of 502 selected cases at the Psychopathic Laboratory of the Police Department of New York City in 1917 showed that fifty-eight per cent were suffering from either nervous or mental abnormalities. Of one thousand offenders examined by the medical service of the Boston Municipal Court twenty-three per cent were feebleminded, 10.4 per cent, psychopathic, 3.17 per cent, epileptic and nine per cent, mentally diseased and deteriorated; 45.6 per cent in all showed abnormal mental conditions. It has been shown that one of the most important causes of recidivism is mental deficiency. The importance of this observation may be illustrated by the fact that of 133,047 persons admitted to the penal and correctional institutions of New York state sixty per cent had served previous terms. Of 25,820 persons received at institutions in Massachusetts during one year, 57.4 per cent were recidivits. Justice Roads is responsible for the statement that of 180,000 convictions in England in one year more than ten thousand represented persons convicted upwards of twenty times previously.

The mental condition of the cases committed to the Matteawan State Hospital is of great importance in a consideration of the relation of crime to the psychoses. Of 2,595 cases admitted between 1875 and 1907 heredity or congenital defects were shown as etiological factors in eight per cent of the total number. Of 793 admissions in which more definite and reliable information was available, hereditary factors were noted in either the paternal or maternal branches of the family or both in thirty-five per cent of the cases. In addition to this, heredity was found in collateral branches in sixteen per cent. Heredity of some kind was thus shown in 51.3 per cent of the whole number studied. Of 3,247 admissions, 46.9 per cent were noted as being intemperate in their habits. An analysis of 576 unconvicted cases in 1912[83] showed that 41.4 per cent were diagnosed as dementia praecox, 21.1 per cent as alcoholic psychoses, 6.9 per cent as paranoid conditions, 4.1 per cent as epileptic psychoses, 7.1 per cent as imbecility with excitements, 2.9 per cent as manic-depressive psychoses, 2.4 per cent as general paresis, 3.1 per cent as undifferentiated depressions, 6.7 per cent as constitutional inferiority and 2.2 per cent as not insane. An analysis of 925 cases committed as insane and charged with criminal offenses attributable to their mental condition shows the more common crimes as follows:—assault (all forms), 26.2 per cent, burglary, 7.8, grand larceny, 8.2, petit larceny, 1, manslaughter, 1.4, murder, 18.9, homicide (total), 22.4, rape, 3.2, and vagrancy, 4.2 per cent.

Nolan [84] has made an analysis of 646 first admissions to Matteawan during a period of six years (1912 to 1918). Forty-eight per cent of these were found to have been born in foreign countries. A striking observation was the large proportion of male cases born in Italy (10.8 per cent) and the female cases born in Ireland (11.7 per cent). Of the various races represented it was noted that the African, which was only responsible for 3.9 per cent of the admissions to civil hospitals, constituted 7.4 per cent of the Matteawan admissions. The races having the largest representation were the Irish (18.7 per cent), the Italian (12.4 per cent) and the Hebrew (10.8 per cent). The mixed races constituted 11.3 per cent of the admissions as compared with twenty-three per cent of the cases reported from civil institutions. Among the male cases 11.4 per cent were charged with disorderly conduct and 26.47 per cent with vagrancy. Of the women, eighteen per cent were charged with disorderly conduct, 16.4 with public intoxication and 39.8 per cent with vagrancy and prostitution. These three groups represent 74.2 per cent of all of the female cases admitted. Of the 646 criminal acts causing commitment, 34.1 per cent were classified from a legal point of view as felonies and 65.9 per cent as misdemeanors. Only 5.3 per cent were charged with murder, manslaughter, etc. Of the various psychoses represented by these cases 26.9 per cent were diagnosed as dementia praecox, seventeen per cent as alcoholic psychoses, 14.7 per cent as constitutional psychopathic inferiority, 7.3 as mental deficiency, 8.3 as manic-depressive psychoses, 11.3 as general paresis, 3.6 as senile psychoses, 2.0 as paranoia or paranoid conditions, 2.2 as epileptic psychoses, and 1.4 per cent as not insane. The alcoholic, constitutionally inferior and mentally defective group constituted thirty-eight per cent of the total. Of the 165 cases diagnosed as dementia praecox it is interesting to note that eleven were charged with homicide, ten with assault in the first degree, fifteen with burglary, thirteen with petit larceny, fourteen with disorderly conduct, and sixty-six with vagrancy or prostitution. Of the seventy-four cases of general paresis thirteen were charged with petit larceny, eleven with disorderly conduct, and twenty-nine with vagrancy or prostitution. The homicides and assaults were committed principally by the alcoholic, dementia praecox, constitutionally inferior and the defective cases. The burglaries and larcenies were committed largely by patients diagnosed as suffering from general paresis, dementia praecox and constitutional psychopathic inferiority.

The type of cases received at an institution exclusively for insane convicts is naturally quite different, as shown by the admissions to the Dannemora State Hospital in New York. Of 185 admissions covering a period of three years the principal psychoses represented were dementia praecox, forty-one per cent, constitutional psychopathic inferiority, nineteen per cent, manic-depressive psychoses, eight, mental deficiency, nine, alcoholic psychoses, five, paranoid conditions, four per cent, etc.

Experience has shown that the defective criminal classes are not suitable cases for either penal institutions or hospitals for the insane. They are unable to adapt themselves to prison discipline or hospital routine and prefer to associate only with persons of their own kind who are given to foolish boasting of their crimes as their least harmful diversion. They are entirely unappreciative of any efforts made on their behalf to improve their condition or fit them in any way for the requirements of society. They are strongly inclined to unprovoked cruelty to others. Often they manifest an apparent interest in religious services, thinking it may lead to some preferment, but not for any moral reason. They are notoriously untruthful, unreliable and exhibit a low cunning which often deceives those not familiar with handling individuals of that type. Curiously enough they are exceedingly critical of others and quick to notice their shortcomings. Sexual perversions and immoral conduct are only too common. Prostitution, as has already been shown, is one of the most common failings of the female delinquent. An interesting but superficial knowledge of legal matters is noted very frequently and paraded with a remarkable degree of egotism which is difficult to understand. It is comparatively an infrequent occurrence for a prisoner to admit that he is guilty of the crime of which he has already been convicted by a court. Only a few years since, a prisoner at Sing Sing wrote the Governor of New York suggesting that his release was indicated as a moral procedure for the good of the institution, as he was convinced from information obtained from others that he was the only guilty man in the establishment. The habitual criminal takes little, if any, interest in his own relatives or family except when he is in confinement, and feels no home ties. There is a curious lack of appreciation for the gravity of his own offense and he always complains of a "frame up" and asserts that he has not had a square deal. Homicides even are always explained in an attempt to show that they were justifiable or unavoidable. The most vicious of assaults are often committed on their fellow prisoners without any provocation of consequence. Experience shows that as a rule they are incapable of any sustained effort and accomplish little or nothing when left to themselves. Tendencies to crime show not only a marked suggestibility but a degree of impulsiveness and a lack of self control which is highly significant.