The approaches of Insanity, are, however, not always slow and progressive: the unhappy victim is sometimes seized without any warning, and where crimes have been perpetrated under such circumstances, it becomes extremely embarrassing both to the judgment of the physician and to the decision of the court; each case, however, must rest upon its own particular merits duly to be weighed and considered both by the judge and jury, lest, to use the expressions of Sir Matthew Hale, “there be on the one side a kind of inhumanity towards the defects of human nature, or, on the other side too great an indulgence given to great crimes.”
Before we proceed to consider the several questions which may arise for the consideration of the medical witness, in the discharge of his forensic duties, we shall offer a few observations upon a point which has frequently given rise to discussion—Whether the existence of insanity cannot be equally, or in some cases, more satisfactorily established, or disproved, by witnesses who are not of the medical profession? by persons, for instance, who have had opportunities of observing the individual, where the same advantages have not been in the power of the practitioner. To this we may reply, that the opinions of the generality of persons on the subject of insanity are extremely vague, and frequently very erroneous,[[528]] and are commonly the result of those glaring exhibitions, those caricatures of disease which the stage represents, or romances propagate; the ordinary observer can hardly be convinced of the existence of insanity, without some turbulent expression, extravagant gesture, or phantastic decoration; while on the other hand he is too apt to infer a state of insanity from those whims and eccentric habits between which the medical practitioner, from daily communication with deranged persons, can alone know how to discriminate; thus was Democritus accused by the people of insanity, but when Hippocrates, by public request, had a conference with the philosopher, he declared that not Democritus, but his enemies were insane. There is moreover a class of maniacs who are so cunning as to deceive those who are not acquainted with the peculiar hallucinations under which they labour; Lord Erskine was thus unable to detect the insanity of a lunatic who fancied himself to be Jesus Christ, until he had received the medical assistance which the presence of Dr. Sims afforded him.[[529]] It is unnecessary to urge any farther the necessity of medical testimony upon such occasions, we shall therefore proceed to consider the different points to which it will be more usefully directed.
Q. 1. Whether the person be actually insane? and what are the proofs of his derangement?
Q. 2. Whether the symptoms are of such a nature as to suffer the individual, with propriety, to retain his liberty, and enjoy his property?
Q. 3. Whether there has been any lucid interval, and of what duration?
Q. 4. Whether there is a probable chance of recovery; and in case of convalescence, whether the cure is likely to be permanent?
Q. 1. Whether the person be actually insane—and if so, what are the proofs of his derangement?
It has been very justly observed, that to constitute insanity it is not necessary to exhibit the ferocity of a wild beast, nor to perform the antics of a buffoon; the most ordinary observer can tell when a person is furiously mad,[[530]] but, in many cases, “such thin partitions do the hounds divide,” that all the skill and discernment of a medical practitioner is required to establish the fact of insanity. It is to such cases as are more likely to become subjects of legal investigation, that the following observations particularly apply. Sir Matthew Hale says, “there is a partial insanity, and a total insanity; the former is either in respect to things, quoad hoc vel illud insanine, where persons are perfectly rational, except on some one particular subject.” This fact is universally admitted, constituting a form of mental alienation to which M. Esquirol[[531]] has bestowed the name of Monomania, and of which every work on insanity abounds with examples. It is in such cases that the value of medical sagacity and experience becomes apparent, and the full developement of the real state of the patient’s mind and opinions will, in some instances, require considerable time and patience. “It is nearly impossible,” says Dr. Haslam, “to give any specific directions for conducting such an examination as shall inevitably disclose the delusions existing in the mind of a crafty lunatic; but in my own opinion it is always to be accomplished, provided sufficient time be allowed, and the examiner be not interrupted. It is not to be effected by directly selecting the subjects of his delusion, for he will immediately perceive the drift of such enquiries, and endeavour to evade, or pretend to disown them; the purpose is more effectually answered by leading him to the origin of his distemper and tracing down the consecutive series of his actions and association of ideas; in going over the road where he has stumbled, he will infallibly trip again.” There is, says Dr. Male,[[532]] a madness which shews itself in words, and another in actions; a lunatic may be coherent in conversation, but insane in conduct; he may be rational when under the restraint of a mad-house, but when released, and at liberty to act according to the impulse of his hallucination, will shew by his conduct that he is really insane.
Although it cannot be difficult to form a diagnosis between the ebullitions of passion, the extravagance of intoxication, or the delirium of fever, and the violence of deportment arising from insanity, yet it may in some cases be not easy to discriminate between this latter condition and that which is associated with excessive enthusiasm; nor is it always easy to discriminate between eccentricity and insanity; do we not, says Dr. Male, see a wretch disinherit his own children, who have committed no fault, and bestow his wealth upon a stranger? another who prefers poverty and rags, and communion with vagabonds, to the social intercourse and proffered kindness of his friends and relations? yet who shall pronounce them to be insane? that they are so, there can be no doubt, and their disease is perhaps of the most unfortunate character, for all their other actions being consistent with sound reason, it is difficult to convince a jury of their insanity, and to divest them of the power of heaping ruin upon their families, and disgrace upon themselves.
The bodily marks which distinguish the insane are, a peculiar cast of countenance, familiar to those versed in the malady; a quick, oftentimes protruded and glistening eye; the body is generally costive; in some cases the insane person is enabled to sustain cold with impunity, and he is insensible to the agency of ordinary stimuli; and the stomach and bowels, from deficiency of irritability, require large doses of medicine to move them; among the physical phenomena of insanity, M. Esquirol observes that few are more constant or remarkable than want of sleep, and that peculiarly disagreeable odour from the body, as well as the excretions of the patients, which impregnates the clothes and bedding. They are devoured with a burning internal heat; and generally have a voracious appetite, and are afflicted with pain in some organ or part, especially the head, the chest, or the abdomen, which the unhappy sufferers are ready to attribute to the malevolence of their enemies.