Kenneth J. Weiss, MD

by Kenneth J. Weiss for the Group for the Advancement of Psychiatry Committee on Art & Humanities

Across the centuries, March has been an eventful month for the 

 on both sides of the Atlantic, and the McNaughten rule remains the prevalent standard to this day.

On March 2, 1843, Daniel McNaughten went on trial for murder, leading to a ruling of not guilty by reason of insanity. The McNaughten Rule has influenced insanity defenses ever since.

In the 1840s, Britain was the scene of protests over the Corn Laws, which stressed lower socioeconomic classes by taxing grain. Prime Minister Robert Peel of the Tory Party was vilified as an oppressor. A Scottish woodworker, McNaughten, became obsessed with Peel, believing he and the Tories were persecuting him, directly and severely enough to threaten his life. Under that fixed idea in 1843, he came to London to study and assassinate Peel in order to save his own life.

On January 20, 1843, McNaughten lay in wait near Peel’s home. A man left the home, and McNaughten shot him from behind. The victim, however, was not Peel; rather, it was his secretary, Edward Drummond. Though it remains 

whether McNaughten knew he was shooting the wrong man,

 sources say the shooter believed he had shot Peel.

 Regardless, the shooting was intentional. The victim died less than a week later, making it a murder case.

On March 2, 1843, McNaughten’s trial began at the Central Criminal Court of London. He had a talented lawyer, Alexander Cockburn. Expert testimony said that as a result of his delusions, McNaughten did not know what he was doing was wrong. Cockburn, who had read 

A Treatise on the Medical Jurisprudence of Insanity

 published in 1838 by American physician Isaac Ray, relied on Ray’s idea that there should not be a single test for insanity. The defense so persuaded Lord Chief Justice Tindal that he directed a verdict of not guilty on the ground of insanity. McNaughten, considered dangerous, was civilly committed, the custom that began in 1800.

On January 20, 1843, McNaughten lay in wait near Peel’s home. A man left the home, and McNaughten shot him from behind. He shot the wrong man.

The verdict did not sit well with Queen Victoria, who had been the object of threats and attempts to harm her. She was incredulous that a man who opposed the conservative government would be considered insane and not responsible. The House of Lords promptly held an inquiry asking legal experts a series of questions. For example: What is the proper test for criminal responsibility?

The consensus was that the correct test is whether the defendant, at the time of the act, labored 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 as not to know what he was doing was wrong.

 This was a cognitive test (knowing right from wrong), in contrast to the volitional test (not having the will to resist an impulse). The new standard became known as the McNaughten Rule, even though McNaughten was not tried under it. It quickly caught on in America, where it remains the predominant standard for insanity.

In the mid-20th century, Dr Ray’s advice was evident. First, federal jurisdiction in 1954 permitted juries to consider a standard Ray supported in 19th century: “an accused is not criminally responsible if his unlawful act was the product of mental disease or mental defect.”

 Then, in 1972, the federal jurisdiction adopted the American Law Institute’s standard (a volitional test in addition to a cognitive test).

On March 30, 1981, John Hinckley Jr shot and wounded President Reagan and his press secretary, James Brady. He was tried and acquitted by reason of insanity under the federal standard. This troubled Congress, just as it did the Crown after the Drummond assassination. The result was the removal of the volitional standard in new legislation-the Insanity Defense 

 of 1984-and a return to the McNaughten Rule.

Group for the Advancement of Psychiatry Committee on Art & Humanities: David Sasso, MD, MPH 

(Committee Chair), Assistant Clinical Professor in the Child Study Center, Yale University School of Medicine

Volunteer Clinical Faculty, University of California, Irvine;

Professor Emeritus, West Virginia University;

Professor, Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College at Thomas Jefferson University;

Associate Clinical Professor in the Child Study Center, Yale University School of Medicine;

Associate Program Director, USC Psychiatry Residency and Child Psychiatry Fellowship; 

Robert L. Sadoff Clinical Professor of Forensic Psychiatry, Perelman School of Medicine, University of Pennsylvania; and

Consult-Liaison Psychiatry Fellow, University of Colorado.

An historical view of the M’Naghten trial

2. DH Tuke. The McNaughten Rule. In CE Goshen (Ed), 

New York, Philosophical Library, 1967, pp 581–614.

A Treatise on the Medical Jurisprudence of Insanity.

Awaiting the Crown’s pleasure: the case of Daniel M’Naughton

5. M’Naghten’s Case [1843] UKHL J16, 8 ER 718.

6. Durham v. U.S. 214 F. 2d 862 (D.C. Cir. 1954).

7. American Law Institute: Model Penal Code (proposed official draft). Philadelphia, PA: Executive Office, American Law Institute, 1962.

8. US Dept. of Justice: Insanity Defense Reform Act. 

www.justice.gov/jm/criminal-resource-manual-634-insanity-defense-reform-act-1984

Articles

Across the centuries, March has been an eventful month for the insanity defense on both sides of the Atlantic, and the McNaughten rule remains the prevalent standard to this day.

Assassins in London and Washington Force Changes in the Insanity Defense

Looking Back to Look Forward
	This Month in Psychiatry

begins a new series: “Looking Back to Look Forward: This Month in Psychiatry.” As part of this series, contributors from across the globe will take the opportunity to point out both notable and neglected figures, topics, and developments in the history of psychiatry. Our hope is that it will inspire a deeper look into the specific topic, the history of mental health, and help us to look forward.

Series Editor Gregory Eghigian, PhD
	Professor of Modern History, Penn State University

 received a Nobel Prize for his work on induced febrile illness to treat the psychosis and neurological consequences of syphilis (dementia paralytica). The first psychiatrist to win the 

, Wagner-Jauregg  began his investigations in 1887.

In the early 20th century, neurosyphilis was regarded as incurable; it led to insanity and death. Syphilis, once known as the great masquerader of clinical medicine, was a worldwide public health menace for hundreds of years before Treponema pallidum was discovered as the infectious agent in 1905.

 Prior to the discovery of T pallidum, Wagner-Jauregg was fascinated by cases of remitted psychosis in which the clinical history included a febrile infectious illness preceding improvement. While the infectious agent was not known when he began his work in the 1880s, there were associations between syphilis, dementia, and progressive paralysis. The standard treatments for syphilis-mercury, iodine, and arsenic, for example-were ineffective and toxic.

 Accordingly, Wagner-Jauregg sought a safer approach.

Inspired by longstanding observations of improved psychosis with fever and encouraged by Robert Koch’s work on isolating tuberculin, Wagner-Jauregg began researching an effective agent to raise body temperature. Tuberculin, alone or in combination with mercury or arsenic, was not clinically satisfactory because many patients relapsed, he told a medical group in Budapest in 1909.
	In 1917, he turned to malaria-induced fever. As he recalled, “I singled out as a particular advantage of malaria that there is the possibility of interrupting the disease at will by the use of quinine, but I did not then anticipate to what degree these expectations from induced malaria would be fulfilled.”

Wagner-Jauregg inoculated nine neurosyphilis patients with blood from a soldier with malaria in 1917. This strain of malaria did not cause severe illness, but it did cause an elevated body temperature of 40â to 41â (104° to 105.8°F). The results of his clinical experiments exceeded expectations-including the remission of neuropsychiatric symptoms-in the majority of participants. Furthermore, the induced malarial illness could be halted with quinine without reversing any improvement in psychosis.

Wagner-Jauregg continued to use the technique, reporting on 200 cases in 1922.

 He insisted that physicians use fever induction early in the course of illness and abandon older methods, stating: “It has become apparent that it is unwise to employ other methods of treatment against paralysis before the malaria treatment, as this means time wasted.”

Wagner-Jauregg began a revolution in psychiatry. In 1927, there were many famous names in psychiatry (eg, Kraepelin, Bleuler, and Freud), all of whom were overlooked for the Nobel Prize. Their contributions were more theoretical, whereas fever therapy for neurosyphilis had immediate empirical support.

Penicillin was discovered in 1928, and eventually rendered fever therapy for syphilis obsolete. (It did, however, earn a Nobel Prize for three scientists in 1945.) The next psychiatrist to win a Nobel Prize in Medicine was Eric Kandel, who earned the prize for his work on the physiological basis of memory storage in neurons in 2000.

Dr Weiss is the Robert L. Sadoff Clinical Professor of Forensic Psychiatry, Perelman School of Medicine, University of Pennsylvania.

Group for the Advancement of Psychiatry Committee on Arts & Humanities: 

David Sasso, MD, MPH (committee chair), Assistant Clinical Professor in the Child Study Center, Yale University School of Medicine; Anish Ranjan Dube, MD, MPH, Volunteer Clinical Faculty, University of California, Irvine; Donald Fidler, MD, FRCP-I, Professor Emeritus, West Virginia University; Andrew Lustbader, MD, Associate Clinical Professor in the Child Study Center, Yale University School of Medicine; Chris Snowdy, MD, Associate Program Director, USC Psychiatry Residency and Child Psychiatry Fellowship; John Tamerin, MD, Greenwich, CT; Kenneth J. Weiss, MD; and , and Helena Winston, MD, Consult-Liaison Psychiatry Fellow, University of Colorado.

1. Wagner-Jauregg J. The treatment of dementia paralytica by malaria inoculation. Nobel Lecture. December 13, 1927. Available at https://www.nobelprize.org/prizes/medicine/1927/wagner-jauregg/lecture/. Accessed November 7, 2019.
	2. Tampa M, Sarbu I, Matei C, et al. Brief History of syphilis. J Med Life. 2015; 7(1):4-10.
	3. Wagner-Jauregg J. The history of the malaria treatment of general paralysis, comment and translation from the German by WL Bruetsch. Am J Psychiatry. 1946; 10295):577-582.
	4. Wagner-Jauregg J. The treatment of general paresis by inoculation of malaria. 

 1922;55(5):369-375.
	5. Brown EM. Why Wagner-Jauregg won the Nobel Prize for discovering malaria therapy for General Paresis of the Insane. 

Psychiatric Times begins a new series: “Looking Back to Look Forward: This Month in Psychiatry.” Contributors from across the globe will take the opportunity to point out both notable and neglected figures, topics, and developments in the history of psychiatry.

First Psychiatrist Accepts Nobel Prize in Medicine: December 1927

» Kenneth J. Weiss, MD, for the Committee on the Arts & Humanities, Group for the Advancement of Psychiatry

When did psychiatry begin? Was it with the discovery of the unconscious? Or was it the discovery of neurotransmitters? As it turns out, healers have been treating mental disorders for thousands of years. Modern psychiatry reflects some, but not all, the values and concepts held by early civilizations. Ancient Greek, Indian, Chinese, Egyptian, Hebrew, European, Arabic, and other cultures explored dimensions of mental and physical health and disease. In the 

Group for the Advancement of Psychiatry’s

 (GAP) 2018 most recent installment in our series of videos on the history of psychiatry, the 

 explores how mental illness was understood from post-stone-age cultures through the Middle Ages.

Early civilizations relied on shamans, sorcerers, magicians, mystics, priests, and other approved healers to treat illnesses. Using rituals, incantations, and offerings, sickness could be prevented or healed. Somatic therapies, not unlike neurosurgery, can be inferred from 

 from France (6500 BCE) and China (5000 BCE). For example, skeletal remains of children with marked skull abnormalities and traumas suggest the ways in which humans cared for mentally impaired children 77,000 years ago.

Some ancient peoples believed diseases occurred due to loss of the soul. Shamans entered into trances or altered states of consciousness, enabling their souls to journey into spirit worlds, sometimes into the underworld.

 During the journey, shamans connected to souls of the dead and to living souls that had strayed or been stolen. Interacting with demons and lost souls without losing their own souls, they brought about cures. The shaman acted as both priest and healer.

In Classical Greece (fifth century BCE), philosophers taught “naturalism,” the belief that laws of nature shape our world, as opposed to gods and demons determining human fate. Alcmaeon, for example, believed the brain, not the heart, was the “organ of thought.”

 He tracked the ascending sensory nerves from the body to the brain, theorizing that mental activity originated in the CNS and that the cause of mental illness resided within the brain. He applied this understanding to classify mental diseases and treatments.

Hippocrates developed a theory of chemical imbalance based on four humors: black bile, yellow bile, phlegm, and blood. Disease resulted from disproportions among the humors. His thinking 

 Today the term melancholia (too much black bile) is still in use. Hippocrates may have been “wrong” by current scientific thought, but theories of “chemical imbalance” remain.

In India, the ancient textbook on Yoga Sutra describes dynamics leading to health and illness.

 In later centuries, the external causes of mental illness were attributed to patients’ sins committed during current or previous lives. For example, disregarding important deceased persons, superhuman agents, ghosts, deities, and celestial beings could bring about various symptoms, depending on which spirits were offended.

Chinese texts from 3000 year ago mention neuropsychiatric illness, including descriptions of mania and psychosis with or without epilepsy. “Imbalance” was the mechanism of psychosis. Other conditions described include confusion, visual illusions, intoxication, stress, and even malingering. Psychological theories about stages of human development 

 to the time of Confucius, about 2500 years ago.

During Europe’s Middle Ages, the focus of theories about mental illness shifted back from physiology to spirituality. As Christianity spread, ideas about sin dominated, and the “psychotherapists” of the era were priests rather than physicians. The notion of demons in the Old Testament continued into the writings of the New Testament. Demonic possession remained a basic assumption. Christian physicians embraced some of the old beliefs of the Greeks and Romans, however, the natural therapy of the Greeks was lost as treatment turned to astrology, alchemy, theology, magic rites, and exorcism.

Preoccupation with witches raged throughout the seventeenth century. Tens of thousands of suspected witches, mostly women, were killed. Those accused of witchcraft included individuals who exhibited aberrant behaviors that today would be considered examples of mental illness, while some had no symptoms.

The interplay between supernatural and natural thinking can be seen across ancient cultures. Mental health practices continued to progress and regress throughout the centuries, eventually including the idea of dedicated institutions for the care of the mentally ill. Tensions among culture, religion, and science will continue to shape concepts about the treatment of individuals with mental illnesses. Studying psychiatry’s origins and evolution gives us perspective on our own beliefs and practices.

To view the video on the Ancient Origins of Psychiatry, go to 

https://www.youtube.com/watch?v=u072SnfVMXU

Group for the Advancement of Psychiatry Committee on Art & Humanities: 

David Sasso, MD, MPH (Committee Chair), Assistant Clinical Professor in the Child Study Center, Yale University School of Medicine; Anish Ranjan Dube, MD, MPH, Volunteer Clinical Faculty, University of California, Irvine; Donald Fidler, MD, FRCP-I, Professor Emeritus, West Virginia University; Alan M. Gruenberg, MD, Professor, Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College at Thomas Jefferson University; Andrew Lustbader, MD, Associate Clinical Professor in the Child Study Center, Yale University School of Medicine; Allan Peterkin, MD, Professor of Psychiatry and Family Medicine, University of Toronto; Anna Skorzewska, MA, MD, Staff Psychiatrist University Health Network, Assistant Professor, Faculty of Medicine, University of Toronto; Chris Snowdy, MD, Associate Program Director, USC Psychiatry Residency and Child Psychiatry Fellowship; John Tamerin, MD, Greenwich, CT; Kenneth J. Weiss, MD, Robert L. Sadoff Clinical Professor of Psychiatry, Perelman School of Medicine, University of Pennsylvania; Alexander Westphal, MD, Assistant Professor of Psychiatry and in the Child Study Center, Yale University School of Medicine.

 Gracia A, Arsuaga J, Martinez I, et al. 

Craniosynostosis in the Middle Pleistocene human Cranium 14 from the Sima de los Huesos, Atapuerca, Spain

. Princeton, NJ: Princeton University Press; 1964.

Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium

. New York: John Wiley & Sons, Inc; 2004.

Hippocrates of Kos, the father of clinical medicine, and Asclepiades of Bithynia, the father of molecular medicine

Yoga and Mindfulness Based Cognitive Therapy (Y-MBCT): A Clinical Guide

An introduction to Chinese psychology: its historical roots until the present day

, 2nd ed. Boston, MA: Pearson Education Ltd; 1995.

As it turns out, modern psychiatry reflects some of the values and concepts held by early civilizations.

Psychiatry’s Ancient Origins

Organized psychiatry began in Philadelphia in 1844, when 13 asylum superintendents assembled to form a guild that is now the American Psychiatric Association. They published their proceedings in the 

. While the name may sound quaint and politically incorrect, it is remarkable that the issues they discussed are virtually the same as those being discussed by psychiatrists today: the classification of mental disorders, asylum care, international approaches to mental illness, prevention of harm, and somatic therapies.

Psychiatry constantly reinvents itself, though it may not be always apparent. In our everyday world of scheduling evaluations, wrangling with insurers, documenting progress, and, of course, being compassionate healers, it’s easy to lose sight of the longer arc of psychiatry over the years. The Committee on Arts and Humanities at the Group for the Advancement of Psychiatry (GAP) has set out to fill a void in psychiatric education by publishing a series of videos on the history of the profession.

The Committee embarked upon a whirlwind tour of psychiatry, from ancient times through the present. In the process, Committee members made some eye-opening discoveries about health and illness over time and across cultures and continents. It was amazing to see that cultures around the world struggled with the same issues psychiatrists do today: understanding mental suffering and behavioral differences through the filter of shared beliefs and practices, and applying remedies in accordance with those beliefs.

It was fascinating to review the roots of psychiatry in ancient cultures, since they are still practiced today: the Ayurvedic medicine of India, Chinese focus on the flow of energy (

), and the Greek theory of the humors of the body (imbalanced blood elements are still called 

 [bad mixtures]). An American example is the idea that mental disturbances are associated with inflammation. This led Benjamin Rush and others, in late 18

 century, to try to reduce the heat by bleeding the patient-many times with fatal consequences. Yet current psychiatric research has circled back to inflammation in association with mental illnesses. Perhaps this time psychiatry may get it right.

The video project promoted a growing appreciation of the need to be nonjudgmental about practices of ancient peoples that seemed quaint, unevolved, or based on non-monotheistic spiritual beliefs. The active ingredients of mental health diagnosis and treatment seem to apply in all cultures. They include identification of behaviors or mood states regarded as out of balance (with self, family, culture, general health, shared values, or spiritual domains), the presence of a leader (shaman, priest, or identified medicine-person), and a set of rituals known within the culture to restore balance (somatic interventions, trance states, sleep, special words by the healer, or temple services).

That’s not to say we need to take specific practices without a grain of salt. Yet, if we use Hippocrates’ humoral theory (black bile, yellow bile, phlegm, and blood) as an analogy, how much different is this scheme from psychiatry’s current focus on neurotransmitters? And while discussion of phrenology in the 1800s never fails to elicit snickers, it steered scientific thinking toward a system of diagnosis and treatment. The fact that its underlying principles were disproved does not lessen its impact on the development of modern psychiatry, which today pursues the Holy Grail of correlative neuroanatomy.

The Committee has completed the first installment of a planned series of 6 videos on the History of Psychiatry. Please visit 

 video, and subscribe to our YouTube channel to hear of new installments in our series.

*The members of the Committee on Arts and Humanities at the

are David Sasso, MD (Chair), Aparna Atluru, MD, (fellow), John Cahill, MD, Joseph Carmody, MD, Anish Dube, MD, Don Fidler, MD, Alan Gruenberg, MD, Andrew Lustbader, MD, Allan Peterkin, MD, Anna Skorzewska, MD, John Tamerin, MD, Ken Weiss, MD, and Alexander Westphal, MD.

The first in a series of videos on the history of psychiatry that explore the roots of modern psychiatry in ancient cultures is now available on youtube. Members of the Committee on Arts and Humanities from the GAP invite you to tune in.

A Trip Through the History of Psychiatry

Make no mistake: Dr Torrey is on the side of the patient. He is enraged by the plight of the seriously mentally ill in the postinstitutional era, and he takes aim at a troika of villains-deinstitutionalization, the civil liberties bar, and the antipsychiatry movement. These 20th-century forces have conspired to relegate citizens with mental illness to a deplorable state of neglect that puts us all at risk. The Insanity Offense threads a needle of making us fear the violent mentally ill without stigmatizing them as a group.