lymph- CRIME AND INSANITY. LECTURE V.A LECTURE ON CRIME AND INSANITY ment, and notthe indeterminate detention consequent upon a verdict of guilty but insane. When the attack of excitement

150 A LECTURE ON CRIME AND INSANITY

neoplasm, but sometimes occurs in cases oftuberculosis. The predominant cell in apleural effusion due to new growth is theendothelial cell. Growth cells are practicallynever found though lymphocytes or degen-erated endothelial cells may be mistaken fortlem.

(8) In lymphadenoma there are usuallypalpable discrete glands to be felt in theneck, axilla or groin, and the spleen is oftenenlarged. A mediastinal mass shown byX-ray may, however, be the only sign. Thepossibility of intrathoracic goitre should beremembered.

(9) In hydatid disease the right base isusually the site of the cyst. On X-ray exam-ination there is a translucent area betweenthe shadows of the cyst and that of thediaphragm. There is eosinophilia. Tilecomplement-fixation test is often negative inan unruptured cyst.

(ro) A gumma is very rare, but I haveseen a case in which there was one producingpleural effusion. Stridor may be due tosyphilitic disease.

(ii) In a case running an unusual coursethe possibility of actinomycosis should beborne in mind.

(12) A good general condition and ab-sence of toxaemia should be taken as evidencein favour of neoplasm rather than oftuberculosis.

TREATMENT.If the tumour is malignant the only

possible chance of saving the patient is itsremoval by surgical operation. This chanceis very slight but as the alternative is certaindeath it should be taken unless the tumouris obviously inoperable. In doubtful casesan exploratory operation should always beperformed.The apparent size of the tumour as seen

by X-ray or determined by clinical examina-tion is often due partly to collapsed lung,so that a case should not be consideredinoperable merely because the tumourappears to be large. In one case a large

mass was seen but at the operation thetumour was found to be about the size of awalnut growing in and obstructing thebronchus. It was easily removed and thepatient made a good recovery. It appearedmuch larger on X-ray examination owing tothe associated collapsed lung. A tumourwhich is thought to be malignant andinoperable is sometimes found to be non-malignant and operable.

In no branch of surgery have there beengreater strides in recent years than in intra-thoracic operations, and in skilled handsexploratory thoracotomy is but little moredangerous than laparotomy. Dermoid andhydatid cysts can usually be removed quitesuccessfully and even inthe case of carci-noma of lung lobectomy may be possible.For inoperable carcinoma of bronchus

radium should be used. At present thisoffers but little hope, but it is still in theexperimental stage and in the near futuremay prove as valuable as it is in carcinomaof the tongue or lip. X-ray treatment oftengives good immediate results in lymph-adenoma or sarcoma, but recurrence is therule. Apart from these measures treatmentconsists in relieving the symptoms.

CRIME AND INSANITY.LECTURE V.

GIVEN AT THE MAUDSLEY HOSPITAL, MAY 28, 1929.

,BY W. NORWOOD EAST,M.D., M.R.C.P.

Medical Inspector, H.M. Prisons, England and Wales.

(Conltinued from p. 67.)THE principles involved in the determina-tion of responsibility for criminal acts oromissions resulting from drunkenness anddelirium tremens were outlined in a previouslecture. It is necessary now to refer brieflyto pathological drunkenness, alcoholic auto-matism, and mania a potu before considering

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A LECTURE ON CRIME AND INSANITY

the association of crime with the morechronic forms of alcoholic insanity.

Pathological drunkenness has been definedas " drunkenness that exhibits unusualfeatures, which leads the individual to per-form strange acts, or acts of violence, orwhich produces serious physical symptoms."Another observer states "that pathologicalinebriation occasionally resembles thephysiological variety, the only differenceconsisting in the small quantity of alcoholwhich has induced the condition."Now it is obvious that criminal conduct

will be favoured by the impaired reasoning,and the inability to appreciate consequences,the emotional disturbance, .excitement or

depression, the loss of inhibition, anddissociation from realities which result fromalcoholic intoxication. Clinical experiencealso demonstrates the fact that acts cotm-mitted during drunkenness may be partiallyor completely forgotten, the result dependingupon the amount and strength of the alcoholtaken, the rapidity with which it is druntk,and the susceptibility of the drinker. Andit appears more direct to tell the jury thatpersons with a tendency to mental instabilityare liable to be disproportionately affectedby alcohol, than to use a technical term likepathological drunkenness which mnay con-fuse the jury by its ambiguity, and becomein consequence the subject of reproachfulcriticism by the judge.

Alcoholic automatism is frequently asso-ciated with serious crime, with murder,attempts at suicide and other crimes ofviolence. In this condition more or lesscomplicated and connected acts may becommitted of which there may be no re-collection when the effects of the alcoholhave passed off: The higheli mental functionsare interfered with while the lower braincentres and the spinal cord are relativelylittle affected. The events leading up to thecrime may be connected with the normalconscious life of the subject, or dissociatedtherefrom, as in epileptic automatism. Alabourer, aged 33, married, and living fairly

happily with his wife and two children, wasin regular work and free from anxiety. Hehad no quarrels and no debts of any conse-quence. He had no insane relations andhad never been considered mentally abnor-mal himself. He indulged in a bout ofdrinking lasting three days, going to beddrunk each night. He came home at

midnight, and making a rope with hisleather belt and a piece of cloth, attachedthem to the cistern pipe in the closet andhanged himself by this means. He retainedno recollection whatever of the attempt orof the actions or motive which led up to it.When satisfied that a crime is automatic,

it becomes necessary to differentiate betweenalcoholic and epileptic automatism, as thelatter absolves an accused person fromcriminal responsibility. In some alcoholiccases there is a slight recollection of theevents which take place, but apart from thisthe differential diagnosis may be difficult, forepileptiforin convulsions may occur as a

result of alcoholic toxaemia. And althoughthe withdrawal of alcohol may result in thesubsidence of the motor demonstrations inindividuals who are not epileptogenic, it isto be remembered that essential epilepticsfrequently have fewer convulsive attackswhen under observation removed from thestresses and strains of the outer world.The short and sudden attacks of intense

excitement which sometimes occur as theresult of alcoholic intoxication may beassociated with crime. If the attack passesoff quickly there may be difficulty in dis-tinguishing mania a potu from the violentoutbursts which are common when ag-gressive and impulsive persons drink toexcess. The diagnosis then may rest perforceupon hearsay evidence and inference. Inthese cases the defence may attempt to showthat the accused was unable to form an

intent to commit the crime. If accepted thecharge may be reduced to one of less degree,and the effect may be regarded as more ad-vantageous to the prisoner, inasmuch as itwill involve a definite sentence of imprison-

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ment, and not the indeterminate detentionconsequent upon a verdict of guilty butinsane. When the attack of excitement ismore prolonged there is usually no difficultyin associating the crime with legal insanity.The chronic forms of alcoholic insanity

most frequently associated with crime arechronic hallucinatory insanity, alcoholicpseudo-paranoia, alcoholic pseudo-paresisand alcoholic dementia. Jelliffe and Whitehave directed attention to the fact thatdelirium tremens may precede alcoholichallucinosis. And in pre-war days, whendelirium tremens was common in prisonpractice, it was frequently observed that thedelirium did not run an acute course, andthat hallucinations persisted after the excite-ment had passed off. The impression formedat that time was that this was most likely tooccur in those cases in which the deliriumwas gradual in its onset.

Alcoholic hallucinatory insanity is not in-frequently associated with crimes of violence.The hallucinations may be as terrifying asthose of delirium tremens; the patient mayattempt suicide to avoid a worse imaginaryfate, or he may act in obedience toimaginary commands to kill himself orothers. A man believed that he conversedwith a person in hell, and that he was inwireless communication with a youth andtwo prostitutes, one of the latter concentrat-ing her name and face on him by television.He believed the woman tried to make himmad, and spoke to him through God. Hesaid he had signs from God directing himto kill them. One sign showed itself aswhite waves with a red wave on either side,out of which came three daggers. Anothersign was a revolver, two daggers and a cross.These were together and signified that hewas to kill the youth and the women. Hewas fortunately arrested on a charge ofdrunkenness before carrying out his inten-tions.

Sufferers from this form of insanity areliable to give themselves up for imaginarymurders. In the following case a man gave

himself up for a crime he had committedas the result of hallucinations. He was a

middle-aged widower, who had attemptedto commit incest on several occasions withhis daughter aged I3. He heard imaginaryvoices calling after him in the street accusinghim of the crime; the same thing occurred incinemas and beneath his window at night.He gave himself up to the police in conse-quence, and when his daughter was ques-tioned it was found that the man'sself-accusations were true. The hallucina-tions persisted for some months. Nodelusions were detected at any time.When delusions form the main feature of

the case; as in alcoholic pseudo-paranoia,they usually centre round morbid suspicion,sex jealousy, and delusions of marital in-fidelity. They may be accompanied byhallucinations, and may be expressed at firstonly during intoxication. But as the caseprogresses and they become more fixed anddominating, and self-control diminishes,they are hinted at and then openly declaimedapart from intoxicated interludes. In menthe result may be murder and suicide, orattempted murder and suicide, and in somecases damage to property; in women, childmurder, attempted suicide, and occasionallyunwarranted accusations of marriage. Awoman described in detail her marriagewith a man; it was obviously delusional.She broke a window of the house ofanother respectable man whom she claimedas another husband, but who had no know-ledge of her. She accused him of miscon-ducting himself with other women in herpresence, and alleged he was poisoning her.

It is most important to interview thealleged unfaithful married partner of anaccused alcoholic in order to satisfy oneselfof the delusional nature of the allegations,and to ascertain their evolution. In general,before the victims are attacked they areaware of the delusions and attribute themto a disordered mind. Repeated threatsmay precede a homicidal attack, but theaddict's control may be suddenly lost.

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The delusions may be persecutory, thepatient believing he is followed about andaccused of homosexual or other crimes, andhe may attempt suicide to free himself fromthem or commit crime to gain the sanctuaryof prison, as in the case of a man whocommitted wilful damage for this purpose.

In criminal work the chief interest ofalcoholic pseudo-paresis lies in its differentia-tion from general paresis. Grandiose delu-sions, tremors, ataxy, speech defects andpupillary abnormalities suggesting generalparalysis of the insane may result fromalcoholism. The Argyll-Robertson syn-drome, presumptive evidence of cerebro-spinal syphilis, has been associated withalcohol and the light reflex returned uponits withdrawal. The diagnosis may be com-plicated from the fact that alcoholic sub-jects tend to become infected with syphilis,and the period of observation before trialmay be insufficient to determine whetherthe symptoms improve upon the withdrawalof the drug. But it is to be observed thatin either case irresponsibility will dependupon the presence of legal insanity and notupon the particular poison causing it, bethis alcohol or syphilis.An intemperate man was charged with

stealing a cycle. He was exalted andhad grandiose delusions. He believed hefound one hundred million pounds in thestreet in a man's hat. He said he was goingto keep ten pounds for himself and give therest to his family. His wife reported hehad been kissing shop girls at their work,and a short time before arrest had walkedinto a post office and demanded fiftythousand Treasury notes. His pupils reactedto accommodation but only sluggishly tolight, the knee-jerks were exaggerated, butsyphilis could be excluded.

In alcoholic dementia hallucinations anddelusions may be present, but in most ofthe cases associated with petty offencesthey are absent or transient. The accusedmay only show a slight degree of moralturpitude, failure of memory and inattention,

lack of capacity for sustained effort, lossof interest in the present, unconcern for thefuture and mild confusion, but these maysuffice to render him unemployable andcause trivial crime. A man, aged 54, wascharged with stealing a quart of milk.He was at one time a scientific instrumentmaker, and was later engaged on landsurveying. He had grandiose ideas; hebelieved he had blown up a million menin one explosion during the Great War, andwas himself responsible for stopping theGerman advance. He also believed thathis wife followed him about thinking hepossessed a large sum of money, but he was,in fact, living on unemployment pay. Hisspeech was slurred, the facial expressionvacant, and the pupil reflexes reacted slug-gishly to light. But the knee-jerks werenormal and the Wassermann reaction wasnegative. There were no tremors and noparesis. He was confused, disorientated,and his mental reaction was slow. He wasfacile, apathetic and stupid; his memory,attention, perception, judgment and reason-ing were impaired. He was unable toappreciate his position or the possibleconsequences of his acts.Two further points of interest remain.

Since alcohol removes the higher control ofcerebral function, its effect upon an insaneperson may be to remove the control whichhas enabled him, when sober, to hide hisdelusions from his fellows. A man wassentenced to a term of imprisonment forwilful damage to a certain shop window.On release he promptly smashed the samewindow and came under my observation forthe first time. His conduct whilst awaitingtrial was normal. I strongly suspectedinsanity from the circumstances of thecase but was unable to obtain any evidenceof it. He was convicted of the offence andserved another sentence, during which hisconduct was normal. On release he tooksome alcohol and again smashed the samewindow. When I interviewed him on thisoccasion he became confidential, being still

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under the influence of alcohol, and theexamination disclosed the delusions whichwere responsible for the three offences. Itwas then possible to deal with him as aninsane person.The remaining point to which 1 would

direct attention is that alcoholic insanity isoften recurrent. Some prisoners give ahistory of several attacks, and during theirperiods of convalescence in mental hospitalshave opportunities of observing the sym-ptoms of insanity in their fellow-patients.The alcoholic will not scruple to malingersuch symptoms in his attempt to avoid theconsequences of a future crime. But it mustbe remembered also that a history of re-peated attacks of insanity may indicate anundue susceptibility to alcohol, and feignedinsanity must not be diagnosed except uponunmistakable evidence.There is a tendency to exaggerate the

importance of epilepsy as a cause of crime.Only 0o5 per cent. of the prison populationare epileptic, and the crime in many of theseis not attributable to the disease. Moreover,the proportion of epileptic patients in Broad-moor Criminal Lunatic Asylum does notexceed that in the ordinary mental hospitalpopulation.

Epileptic automatism is frequently set upas a defence in cases of serious crime, andit is important to consider in such cases notonly the family and personal history of theaccused, but also all .the known events con-nected with the crime. There may be con-siderable difficulty at arriving at the truth,more particularly in cunning and mendaciousepileptics who have committed crime, for itmust be remembered that the epileptic assuch is not immune from punishment.Moreover, it may be very difficult to investi-gate a case of alleged epilepsy, and to avoidputting questions to a cunning and alertcriminal without suggesting the answers.After a family history has been inquired intothe next and fundamental step is to establishthe fact that the prisoner is really an epileptic.This being determined the events preceding,

accompanying, and subsequent to the crimemust be closely analysed, to ascertainwhether there is any motive and whether theacts are dissociated fromn the ordinaryconscious life of the accused.

Certain points connected with epilepticautomatism assist the diagnosis. The dreamstate is more conspicuous and prolongedafter minor epileptic attacks, and.may occurinstead of a fit-the so-called epilepticequivalent. Mercier considered that auto-matic action never followed fits that wereextremely severe. He also stated that whenautomatic action occurred after any one fitit followed other fits in the same person.But an epileptic of many years' standing onlyknew of one automatic act, although hesuffered previously and subsequently fromrather frequent major attacks. He reachedhome one evening and found his wife andthe maid were out. He took off his coat tolight the sitting-room fire and rememberedbeing about to put some coal in the grate.He remembered nothing more until he foundhimself in the street nearly a mile from homein his shirt sleeves and with the coal scoopin his hand. He had crossed busy suburbanroads in a state of oblivion.

Automatic action may be of the same typein the same patient. Dr. Aldren Turnerdescribes the case of an epileptic who auto-matically took out his watch after he hadhad a fit. A prisoner thrice indecently ex-posed himself during periods of automatism,and some patients can be observed to attemptto undo their clothing after a fit. In othercases the automatic acts may vary. Dr.Aldren Turner records the case of an epilep-tic who sometimes turned out the contentsof his pockets, and on other occasions wasobserved to pile the crockery on the dinnertable, and at other times became aggressiveafter a fit. In a case with which 1 was con-cerned an affectionate husband cut his wife'sthroat as she lay in bed. Seen a few hourslater he described how he rememberednothing after leaving the lavatory until hefound himself standing over his dead wife.

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He was greatly distressed and said that hereturned to the bedroom three times beforehe could convince himself that what he sawwas true. He gave himself up to the police,and no motive for the crime was discovered.But his relations described how he had onone occasion thrown a handful of gold andsilver money on the fire and refused to allowthem to rescue it. On another occasion hewas nursing a favourite dog and suddenlythrew it through a window. He had alsobeen aggressive and violent when dissociated.Tlhese dream states were spontaneous, un-provoked, unconnected with precedingevents, and were followed by completeamnesia. He was found to be insaneat his trial.

Post-epileptic action is usually of thenature of an habitual act or the caricatureof such an act. Witness the case of thewoman who was cutting bread and butterfor her children's tea when she had a fit, andin the subsequent automatism cut the armof one of her children so that it died. Inanother case a highly respectable man,devoted to his family, after a period ofmental stress suddenly attacked his wife andtwo daughters with a coal hammer. Hiswife died from the injuries she received.The accused stated that he was following hisusual custom and was about to make hiswife a cup of early morning tea. Whilst thekettle was boiling he commenced to breakup some coal with a hammer and remem-bered hearing the kettle boil, then he saidblood came from the coal and he found hisdaughter standing by the front door withblood on her face saying he had struck her.He at once went to the police station andtold them to come to his house. There wasno motive for the crime and no reason todoubt his statement that he had no recollec-tion of what he had done. He was foundguilty but insane at his trial.

Thle automatic actions of the epileptic maybe transient or prolonged, simple or complex.The cross-examination of the medical wit-ness genlerally centres round the questionwhether or no any recollection of an auto-

matic act persists when the subject regainshis normal mental state. Savage, Mercier,Maudsley, Hack Tuke, Jelliffe, GordonHolmes, and other authorities consider thatthe epileptic preserves no memory of hisactions on his release to his normal level.This conclusion is of the utmost importancein certain cases. Frequently a prisonermakes a voluntary statement to the policewhich shows that he has some memory ofhis criminal actions. If there is a partialamnesia the explanation of the facts is oftenfound in a history of alcoholism, Jacksonianattacks or hysteria. W. A. White observes:The amnesia of epilepsy is absolute, but inhysterical amnesia there are islands ofmemory varying on going over the sameground on different days. The field ofmemory fluctuates. And I would add.thesame phenomenon is frequently present incases of feigned insanity. Indeed themajority of alleged amnesias associated withcrime are feigned.

Epileptic automatism absolves an accusedperson from responsibility for a crime if itis accepted by the jury, for it is a temporarydisease of the mind which prevents the indi-vidual from knowing the nature and qualityof his act and that it is wrong. The condi-tion is so frequently alleged withoutjustification that a recapitulation of itscharacteristic features may be excused. Ingenuine cases the accused person is knownto be an epileptic, that is, to have sufferedpreviously from major or minor attacks orepileptic equivalents; the crime is motive-less; the automatic actions may be uncon-nected or appear to be continuous withthose immediately preceding them; they maybe connected and show purpose during theautomatic period, but are dissociated andpurposeless in relation to the normal con-scious life of the individual; they maybe caricatures of actions habitually performedby him; they may repeat themselves insuccessive automatisms and there is norecollection afterwards of what took placeduring the automatic state.

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Bearing these facts in mind the followingcases are given at some length for purposesof comparison. In the first the symptomswere feigned, in the second genuine: Ayoung man was charged with attemptedmurder. He courted a widow who did notrespond to his advances and he becamejealous of her, and sent letters to herthreatening her life and falsely alleging thatimmorality had taken place between them;he also made veiled threats at suicide. Hewas forbidden the house on account ofhis conduct. On a certain afternoon thewidow and her daughter arrived home, andthe accused tip-toed into the room in whichthey were. They inquired how he got inand he replied by the front door; he wastold this was untrue as the door was lockedand hle was ordered out. He refused to go,and after further words attacked the widowwith a sharp instrument causing her seriouswounds; he also injured the daughter'shands when she came to protect her mother.The women screamed and got away fromhim, and as they left the room the accusedmade a motion across his throat with some-thing shining in his hand. A police officerarrived and closed with him. He then said,"Where am I ? Oh my head!" He wasexamined by the police surgeon, who foundnothing abnormal about him and no evidenceof any injury. A table knife and blood-stained razor belonging to his own homewere found in the room. The accused gaveme a history of attacks of giddiness, in whichhe said everything became dark, that he thenfell down and became unconscious for fromtwo to ten minutes, or longer. He at firstsaid that he did not become drowsy after anattack, but later amended this after a some-what leading question, and stated that " hemight feel sleepified after an attack." Healleged that the attacks occurred every weekand sometimes twice a day, and that he gotdrunk about twice a week. A near relationwas interviewed and said the accused wasnot intemperate, had never had any attacksof falling or unconsciousness, but had a vile

temper and had attempted suicide whenout of employment. The accused deniedany recollection whatever of the attack onthe two women. He alleged he had norecollection of taking the table knife aiid razorfrom his home, but remembered being in apublic house a little later and drinking andplaying a game there with some men. Hethen alleged a period of which he retained no

memory during which the crime took place,his memory not returning until he was in thehands of the police. According to his ownstatement, therefore, the early events con-nected with the crime-taking the knife andrazor from home-were forgotten, the nextremembered-drinking and playing in thepublic house-later events forgotten, andstill later recollected. Compromisingactions were forgotten ahd excusing onesremembered. Whilst awaitingtrial hleallegedattacks of unconsciousness but there wasnothing to support this, although he wasunder the constant observation of trainednurses. He alleged he had not passed urinefor three days, but his bladder was empty.He was regarded as a calculating and clumsymalingerer, and was found guilty at histrial and punished.Very different is the history of a genuine

case: A manual labourer, aged 45, single,of good character and temperate habits, wascharged with being on enclosed premises.Ten years before, he received a blow on thehead which rendered him unconscious forabout four hours and caused his detentionin hospital for five weeks. The situation ofthe injury was marked by a scar. He com-plained that he had never been right since,and suffered from diplopia, giddiness, head-aches and fainting fits in which lie lostconsciousness, and had been told he felldown and struggled. He had bitten histongue in these attacks; he never urinatedin them, but sometimes went to sleep after-wards. He lost no work on account of hisattacks as his mates could tell when theywere coming on. They told him "he stoodand studied," and they stopped him working

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then and looked after him until the attackwas over. A female relation who lived withhim confirmed these details; she said the fitslasted about three minutes, and the accusedhad related to her periods when he lostconsciousness outdoors. He had beentreated at two hospitals for fits and had beenout of work a year at the time of the offence.He stated that on three or four occasionsrecently when out of doors he had foundhimself in some strange locality, and hadnot known how he had reached there, buthe had had no convulsive attack for threeionths at the time of the offence. He wentthrough the open door of a house andpicked up a baby placed in a perambulatorinside the entrance and walked upstairswith it in his arms. The mother, hearingthe infant cry, came down and met theaccused and tried to get the baby from him,but unsuccessfully. She became alarmedand ran out for a policeman. Returningwith the officer they met the accused comingout of the house without the baby, who wasquite unharmed. She said that he thenseemed quite a different man. The accountthe accused gave was as follows: he remem-bered listening to an outdoor meeting onunemployment in the same street as that inwhich the house was situated, then came acomplete blank until he found himselfstanding between two policemen outside thehouse of the prosecutrix. On examinationthe prisoner's facial expression was vacant,the pupils reacted to light, the knee-jerkswere normal and the plantar reflexes flexor.Tremors of the tongue were present. Hismental reaction was slow. He was apatheticand unconcerned at his position and showeda lack of interest in current affairs.One day when under observation he

walked to the door of the prison hospitalward saying, " I'm coming, l'm coming," andappeared to an experienced nurse to be quiteunconscious of his surroundings. He wasgot to bed at once, and was seen almostimmediately by a medical colleague. Hewas then conscious but had no memory of

what had just occurred, and the plantarreflex gave an extensor response for a shorttime. The following points favoured thediagnosis of epileptic automatism. He wasa recognized epileptic who had previousautomatic periods, and an undoubted auto-matism when under observation ; he showedalso some permanent mental deteriorationas the result of epilepsy. The crime wasmotiveless and was unconnected with theevents immediately preceding it ; his actionswere dissociated and purposeless in relationto his normal conscious life; they wereperhaps a caricature of actions associatedwith a nephew, aged 2, of whom he was saidto be very fond; and his statement that hehad no recollection of his conduct wasconsistent with the known facts of the case.

Mental depression, the result of epilepsy,may lead to attempts at suicide, anddementia secondary to this disorder is notinfrequently associated with minor crimes.Epileptic excitement (furor) may result incrimes of violence, and the actions thencommitted may be remembered by theaccused. A recognized epileptic had a fitin the street and cut his face; the ambulancewas sent for, and when he was asked to goto the hospital in it he became extremelyviolent and abusive, striking and kickingthose who had endeavoured to befriend him.He remembered what he did. He appearedto have had previous attacks of a similarnature, as the neighbours were reported tobe afraid of him.

It is sometimes suggested to the medicalwitness that the violence of an epileptic isdue to the well-known fact that he may beunduly aggravated by opposition during aseizure. This may happen in cases ofepileptic excitement, as seen in the abovecase, but is not always so. The circum-stances of many automatic crimes haveprecluded any previous provocation.The manic-depressive psychoses may

result in criminal conduct even when theaccused is only slightly affected by the dis-order. There is, however, a very marked

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158 EDITORIAL

difference in the type of crime committed bythe excited or depressed patient. In maniathe most common crime in a series of 52cases was that of theft, io cases; next inorder of frequency were crimes associatedwith insulting words and behaviour, 8 casesand there were 7 crimes of violence, 6assaults and I murder. In 53 cases ofmelancholia there were 34 cases of violence,17 attempts at suicide, IO murder, 6 at-tempted murder, and I for causing grievousbodily harm. There were only 4 cases oftheft, and 3 of insulting behaviour. Theremaining cases in either group were un-important in themselves, and the contrast inthe two groups less marked.The trivial nature of the crime so often

associated with mania is probably due inpart to the fact that the mania'c directs theattention of others to himself, and to thenecessity of protecting them from the con-sequences of his conduct. It seems alsodue in some measure to the fact that theslighter cases exercise some control overtheir conduct, and that when the excitementis more severe their actions lack the pre-meditation and co-ordination found in manycases of melancholia.The mild cases of mania and melancholia

may present serious difficulties in diagnosis.If slight cases of mania pass unrecognizedthere is less likelihood of serious crimeresulting than when this happens in slightcases of melancholia, for comparativelymild degrees of depression sometimes causemurder and attempts at suicide. The natureof the offence in mania or melancholia oftensuggests mental disorder. A man with ahistory of two previous attacks of insanitywas arrested for stealing pieces of carpet onwhich door-step cleaners knelt to do theirwork. He was restless, excited, exalted,talkative and boastful. He said that heprovided Jack the Ripper with women forthe purpose of mutilation. He was arrogant,devoid of decency and suffered from in-somnia, and it was necessary to certify himas insane. In cases of melancholia the only

rational explanation of the murder of aloved one may be mental alienation.There may be some difficulty, when an

accused person first comes under observa-tion before trial, in deciding whether thesymptoms are due to mania or alcohol or acombination of both. A man was chargedwith beingdrunkand disorderly. He failed togain admission into a Poor Law institutionand went to a police station to complain.He became so obstructive there that it wasnecessary to arrest him. When he cameunder observation there was no evidence ofexaltation, confusion, disorientation, delu-sions or hallucinations, but he was hostile,truculent, excited and talkative. I inclinedto the view that he was suffering fromhypomania but had insufficient evidence tocertify him. A few months later he returned,again charged with being drunk and dis-orderly. His condition was now aggravatedand grandiose delusions were also manifest.It was clear he was passing through anattack of mania and was dealt withaccordingly.

(To be contiinued.)

EDITORI AL.FINAL FELLOWSHIP CLASSES.

IT is proposed to hold in the autumn aseries of special classes in Clinical Surgeryand Pathology. Although intended pri-marily for those who are entering for theFinal Fellowship Examination of the RoyalCollege of Surgeons in November, theclasses will be open to all post-graduates.These classes are not intended to take the

place of the various Fellowship Courses heldat certain hospitals, but are intended toafford intending candidates an additionalopportunity of examining patients and beingquestioned on the diagnosis and treatmentin a manner similar to that which obtains inthe Fellowship Examination.



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lymph- CRIME AND INSANITY. LECTURE V.A LECTURE ON CRIME AND INSANITY ment, and notthe indeterminate detention consequent upon a verdict of guilty but insane. When the attack of excitement