Homicidal insanity has remained a vexation to both the psychiatric and legal professions despite the panorama of scientific and social change during the past 200 years. The predominant opinion today among psychiatrists is that no correlation exists between dangerousness and specific mental disorders. But for generation after generation, psychiatrists have reported cases of insane homicide that were clinically similar. Although psychiatric theory changed and psychiatric nosology was inconsistent, the mental phenomena psychiatrists identified in such cases remained the same. The central thesis of Homicidal Insanity is that as psychiatric theory changed, psychiatrists regarded these phenomena variously as symptoms of mental disease or the disease in itself. It is possible to trace these phenomena throughout the history of Anglo-American psychiatric theory and practice. A secondary thesis of the book is that psychiatrists have used these phenomena as predictors and markers in the practical matters of preventing insane homicide and of testifying in the courts to defend the irresponsible and expose the culpable.For 200 years, scientific and philosophical disagreement raised controversy and brought the issues to public attention. Still, to this day no rational method exists to discriminate the dangerous from the harmless in matters of involuntary commitment, nor insanity from crime in the courts.
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Homicidal Insanity, 1800â"1985
History of American Science and Technology Series
By Janet Colaizzi
The University of Alabama PressCopyright © 1989 The University of Alabama Press
All rights reserved.
The Issue of Insane Homicide
Early in the 1980s, a person who had been under psychiatric care attempted to assassinate the president of the United States. The mass media used this occasion to raise the question of why psychiatrists permitted disturbed and dangerous patients like John Hinckley to move freely in society. The expectation that doctors could and should restrain dangerous lunatics has deep roots in the past. The consequent professional dilemma emerged not only in the case of John Hinckley but also throughout the history of psychiatry.
That some mentally ill persons kill is well documented from ancient times to the present. But murder is far from rare, and most murders are not committed by lunatics. Even before there were any medical specialists in mental diseases, a physician was often summoned to decide whether or not a mad person was dangerous.
This book is about homicidal insanity. Its purpose is to describe how physicians have diagnosed, explained, and restrained the dangerous insane from the beginning of medical care for the mentally ill to the present. The issue of homicidal insanity is embedded in the scientific and social history of medicine on the Continent and in the United States; and, despite the panorama of change over a 200-year span, it has remained a central social issue and a conundrum for psychiatry.
From the beginning, it was clear that some lunatics were harmless and some were dangerous. Psychiatrists had to find ways to diagnose homicidal insanity. Early medical writers on insanity, notably Philippe Pinel in France and Benjamin Rush in the United States, instructed their readers on the differential diagnosis and management of dangerous lunatics. As the literature of insanity grew, European, British, and American writers recounted celebrated cases of insane homicide and contributed their own clinical experience. Throughout nearly 200 years of Anglo-American psychiatry, cases of insane homicide were reported that were clinically similar, generation after generation. Although the nosology was inconsistent and subject to debate and controversy, the mental phenomena these early clinicians identified as evidence of homicidal insanity were the same.
The predominant opinion today among psychiatrists is that no correlation exists between dangerousness and specific mental disorders. Research published in the last two decades has failed to demonstrate any positive correlation between mental illness and criminal offenses. Although psychiatrists have not found a correlation between insane homicide and any disorders classified in the Diagnostic and Statistical Manual III, the current literature reflects the belief that specific mental phenomena are predictors of dangerousness when the patient's social situation is taken into account.
The organizing principle of the nosology during the early decades of the nineteenth century was faculty psychology. Psychiatrists focused upon the manifestations of the disease and subdivided insanity into derangements of the intellect, the emotions, and the will. Later in the century, medical science developed organ and cellular pathology. But psychiatry had no such science.
Theories of Homicidal Insanity
Scientific, intellectual, and social changes influenced the way in which psychiatrists explained insanity. Throughout the nineteenth century, they agreed that it was disease of the brain. Some theorists conceived of localized brain functions and suggested that homicidal insanity could be traced to the pathology of specific cortical structures. But the examination techniques of the times failed to reveal any differences between the brains of homicidal lunatics and harmless lunatics; and, except for brain tumors and vascular disorders, between the brains of the insane and the sane. Later psychiatrists maintained the somatic model, but believed that insanity was a diffuse rather than a localized cortical disease. Lacking a specific brain pathology, they continued to think in terms of a phenomenology of insanity.
Most nineteenth-century psychiatrists believed that the brain was affected by outside forces or by any organ of the body. Knowledge of the pathways and mechanisms through which these influences reached the brain changed with an evolving medical science. Still, situational and physiological forces could derange the brain and cause insanity. It followed logically that intense forces could produce homicidal insanity.
With the rise of psychoanalytic concepts, some psychiatrists posited dynamic explanations for insane homicide. This theoretical excursus did not displace the predominant somatic model. In both models, however, interest in the hereditarian and constitutional origins of dangerous insanity has continued throughout two centuries.
Involuntary Commitment and Restraint
Psychiatrists applied their theoretical knowledge and belief to the practical matters of prediction and prevention. At first, the predominant issues were the management of homicidal lunatics in the asylum and the question of when to turn them loose. Not all asylum superintendents had the legal authority to discharge patients, but generally this decision was their responsibility and they were morally, if not legally, responsible for any harm caused by a former patient.
Involuntary commitment to an asylum was not restricted to the homicidal insane. The belief that the mentally ill, whether dangerous or harmless, should be restrained for their own good is firmly rooted in Anglo-American law. Throughout the nineteenth and well into the twentieth century, psychiatrists and social thinkers regarded the mentally ill as absolutely incompetent and subject to the guardianship of the state. Dorothea Dix, the nineteenth-century reformer of psychiatric care, argued that the state is responsible for providing care to these helpless insane. The doctrine of parens patriae, that the state should relate to its citizens as a parent to the child, was the basis for involuntary institutionalization of all the mentally ill.
Social thinkers challenged parens patriae from time to time, but is has only been since the social changes of the 1960s that the criterion of dangerousness has predominated in psychiatric and legal thinking. Civil libertarian thinkers believed that no amount of humanitarian concern was sufficient to deprive citizens of their liberty. Although this belief has influenced involuntary commitment from time to time over the past 200 years, it has only been since the 1960s that increased attention to the standard of dangerousness has led to revision of commitment statutes in most states. More and more, the sole criterion for involuntary commitment is becoming this standard. Yet, since 1974, the official position of the American Psychiatric Association has been that it cannot be predicted.
Insanity and Crime
Early in the development of the specialty, psychiatrists were called upon by the legal system to defend the irresponsible and to expose the culpable. Both medical and legal experts searched for the elusive test for insanity. Substantial controversy within both the medical and the legal professions has honed the essential questions, but no rational method exists to this day to discriminate insanity from crime.
Theoretical formulations directly affected the methods psychiatrists used to separate the insane from the criminal. Religious ideas about the brain/mind relationship collided with problems of free will and responsibility. Most psychiatrists adopted the tenets of the Scottish common-sense school, which balanced the objective physical reality of human existence with theoretical concepts about innate moral faculties. The philosophical and scientific dilemmas of both psychiatry and the law have been no more evident than in the courts.
Phenomenology of Homicidal Insanity
The central thesis of this book is that, from the beginning, psychiatrists have associated homicidal insanity with certain psychiatric phenomena. The term phenomenon is used in this context because, as theory changed, practitioners regarded such events variously as symptoms of mental disease or the disease itself. Further, some theorists regarded a particular phenomenon as pathological, but others regarded it as insignificant or denied its existence altogether. Some psychiatrists believed that the appearance of these phenomena in a particular patient clearly made that person dangerous. It is possible to trace these phenomena throughout 200 years of Anglo-American psychiatric theory and practice (figure 1). These phenomena are: (1) delusions; (2) command hallucinations (Intellectual Insanity); (3) lack of remorse, or "moral feelings"; (4) morbid impulses (Emotional Insanity); and (5) mania, or "frenzy" (Volitional Insanity).
A secondary thesis is that psychiatrists have used these predictors in the practical matter of preventing insane homicide. Notwithstanding the philosophical, scientific, social, and legal vexations involved, practitioners are clearly responsible for the dangerous insane. In many instances throughout history, they have been given this responsibility with an attenuated authority or with no authority altogether. Still, they were and still are expected to know the difference between the dangerous and harmless insane so that both insane homicide and unwarranted involuntary commitment to mental hospitals can be prevented.
Although the narrative in this volume focuses upon Anglo-American physicians, psychiatry as a medical specialty began in eighteenth-century Europe with the social and scientific changes of the Enlightenment. Early nineteenth-century Anglo-American physicians who were seeking to reform the care of the insane looked to European medical authority. To understand how these physicians rationalized their reforms, it is necessary to describe how European ideas were transferred and intertwined through a growing body of clinical experience with the insane.
The story begins at the end of the eighteenth century when the theoretical constructs and lessons learned from contacts with insane patients coalesced into the first medical writings on the subject. Anglo-American physicians took these European ideas, added to them, and formulated their own principles, methods, and techniques. The establishment of asylums and hospitals for the insane institutionalized these reforms.
During the early decades of the nineteenth century, both American and British psychiatrists addressed the jurisprudence of insanity. Throughout the entire history of psychiatry, legal issues commanded the profession's attention. The question of responsibility and justice in insane homicide is a major theme throughout this book.
Psychiatrists have confronted the problem of homicidal insanity in a number of scientific and social contexts. The following chapters trace the intellectual and social changes in the United States and Great Britain over the nineteenth and twentieth centuries and show how they affected psychiatric theory as well as practice in general and particularly in relation to homicidal insanity.CHAPTER 2
The Theoretical Boundaries of Dangerousness 1800–1840
In the United States during the last decades of the eighteenth century, the idea that lunatics should be given medical care in asylums evolved from a number of social and intellectual changes. Among the several changes that guided this transition from family and community care to medical and institutional care, the most evident was the mere fact of population: more lunatics needed to be reckoned with in the growing colonial towns. And, because transients were among the group, the usual practice of family isolation became inapplicable. In complex social groups working together toward common goals, even the merely disruptive are apt to be regarded as dangerous.
The royal governor of Virginia, Francis Fauquier, called for a mental hospital in 1766 and again in 1767. In 1766 his brief message to the opening session of the House of Burgesses reflected Enlightenment beliefs about insanity as the loss of reason, the desire for order in the community, and the idea that the care of the insane was the responsibility of physicians. According to Norman Dain, the real impetus for the hospital project came from an editorial in the Virginia Gazette:
A most shocking murder was perpetrated yesterday morning on the body of Mr. Charles Thompson, who lived a little distance from York, by his wife, who for some years past has been out of her senses. He got up early in the morning and walked over his plantation, and when he came home lay down, being much troubled with the headache. He had no sooner got into a doze than his wife came, and with a broadaxe broke his scull to pieces, by repeated strokes. He has left a large family of helpless children. The woman is secured, but seems quite insensible of the horridness of the crime she has committed. (It is really shocking to see the number of miserable people who have lost the use of their reason, that are daily wandering about, for want of a proper house to keep them confined in. If there had been such a place, this poor man would not have met with the above untimely end.)
Undoubtedly, as in Virginia, the reform spirit also played a role elsewhere in the shift from family to medical care. Medical and social historians place the genesis of insane asylums squarely within the Enlightenment and post-Enlightenment ideology, which included the concept that even the less fortunate members of society had and could achieve their natural rights. The intellectual changes of the Enlightenment, followed by the scientific interest in emotional life, supported the sentimental humanitarianism that catalyzed the institutional approach. The humanitarianism that arose during the later Colonial period was rooted in the theory of environmentalism and the idea of progress, that it was within the capacity of man to improve his individual and social conditions.
By the beginning of the nineteenth century, American physicians were largely apprentice-trained and gained only a minimum of theoretical knowledge. By this time, however, hospitals were growing in number and size, particularly in Europe, and the concentration of large numbers of patients in one place provided data for the study of medicine. Physicians were turning to clinical experience as a source of knowledge and began questioning the value of the standard therapeutics that had been handed down virtually unchanged from physician to apprentice for generations. This change was particularly notable in France, where new techniques and new instruments, such as the stethoscope, for example, turned physical diagnosis into a clinical discipline.
By 1820 the French clinical school had begun to have a direct impact upon physicians in the eastern United States, where asylums for the insane were already being established. Under the influence of French clinical empiricism, first on the Continent and then in Great Britain and the United States, physicians began to believe that insanity was a somatic disease and therefore curable. This thesis was reinforced by A. L. J. Bayle's discovery that the symptoms of certain types of insanity could be traced to a definable pathological finding: a chronic inflammation of the brain membrane.
The growth of medical care for the insane in the United States and Great Britain faithfully reflected Continental advances. Even before American physicians began to flock to Paris to study at the large French clinics, William Tuke in England and Benjamin Rush in Philadelphia had already begun clinical treatment of the insane. Moral treatment, an outgrowth of the Enlightenment spirit of humanitarianism, formed a part of the therapeutics, but Rush and his followers also believed that insanity was a somatic disorder and they emphasized medical therapy.
The impetus for American medical interest in the subject, however, came principally from the practical realities of general practice in growing communities. Except for Benjamin Rush and George Parkman, early writers on insanity had no experience in asylum care when their first works were published. Their interest was a response to perceived social need to care for and to protect their charges from injustice. Parkman, for example, in his proposal for the establishment of a retreat for the insane, declared in 1814: "The patient will be courteously received at the Retreat, as a stranger, and he shall not discover that his misfortune is known there, until maniacal extravagance demands his restraint."
Up until the early 1800s, the task of identifying dangerous lunatics did not require any special expertise. But, as the medical profession appropriated responsibility in the field, the task became more complex because clinical observers were identifying not just insanity but its subtle forms.
The Problem of Homicidal Insanity
Within this context, physicians observed that some lunatics were dangerous and some were not and sought to describe and name the homicidal insanities as well as to differentiate them from the harmless types. From the beginning of this new phase of embryonic psychiatry, the fundamental question of the lunatic's potential dangerousness pervaded the discussions of classification of mental disorders and differential diagnosis.
Excerpted from Homicidal Insanity, 1800â"1985 by Janet Colaizzi. Copyright © 1989 The University of Alabama Press. Excerpted by permission of The University of Alabama Press.
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Table of ContentsContents Foreword 1. The Issue of Insane Homicide 2. The Theoretical Boundaries of Dangerousness, 1800-1840 3. The Development of a Medical Jurisprudence of Insanity 4. From Static Brain to Dynamic Neurophysiology, 1840-1870 5. The Non-Asylum Treatment of the Insane 6. Homicidal Insanity and the Unstable Nervous System, 1870-1910 7. Psychoanalysis and Medical Criminology 8. Somatic and Dynamic Dangerousness, 1910-1960 9. Prediction, Confidentiality, and the Duty to Warn 10. The Phenomenology of Homicidal Insanity Notes Bibliography Index