In deciding upon that species of insanity which is termed Melancholia, we must be cautious in not confounding its symptoms with those of Hypochondriasis, which is to be regarded as strictly a bodily malady; the following remarks of Dr. Cullen may tend to direct our judgment upon this interesting subject.
“Hypochondriasis I would consider as being always attended with dyspeptic symptoms; and though there may be, at the same time, an anxious melancholic fear, arising from these symptoms, yet while this fear is only a mistaken judgment with respect to the state of the person’s own health, and to the danger to be from thence apprehended, I would still consider the disease as hypochondriasis, and as distinct from the proper melancholia. But when an anxious fear and despondency arise from a mistaken judgment with respect to other circumstances than those of health, and more especially when the person is at the same time without any dyspeptic symptoms, every one will readily allow this to be a disease widely different from both dyspepsia and hypochondriasis.”
With respect to the phantoms[[533]] which occasionally appear to the hypochondriac, and are described by him as having all the semblance of reality, Dr. Haslam remarks, that although a person may labour under a delusion, by seeing and hearing those things which do not exist, yet if his belief in their reality is not subscribed, but, on the contrary, he knows them to be delusions,
“A false creation, proceeding from the heat-oppressed brain,”
and he is persuaded that his perception is beguiled, no inference in favour of the existence of insanity ought to be deduced; if, however, he should believe in their reality, and commit an act in consequence of such a conviction, he may be justly considered insane—it is the belief that, physiologically, constitutes the disorder.
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?
We have already offered some observations upon this point, (page [302]); the medical practitioner in delivering an opinion that may involve the liberty of the person, cannot well be too guarded in his evidence. As each case must rest upon its own merits, the subject scarcely admits of any general elucidation beyond that which we have already endeavoured to bestow, and the plan of our work must of necessity preclude the more minute details. We must, however, here observe, that coercion should never be employed but as a protecting restraint—to guard the patient from doing mischief to himself, or offering violence to others; and for this purpose the straight-waistcoat is generally sufficient: formerly, coercion was employed with a degree of severity that amounted to vindictive punishment, recourse was even had to the whip, and stripes were actually inflicted by medical direction; while asylums for the reception of the insane, were considered as prisons for safe custody and punishment, rather than as hospitals for the treatment and cure of this most dreadful malady.
Q. 3. Whether there has been any lucid interval, and of what duration?
This is a question which a medical witness is always called upon to answer. By the term lucid interval, we are not to understand a remission of the malady, but a total suspension of it—a complete, although only a temporary, restoration of reason. The question is generally beset with difficulties, and requires all the penetration and experience of the physician to arrive at a safe conclusion; for in many cases the patient is enabled for a limited period to converse rationally, and where he is desirous of carrying any particular plan into execution, to dissemble so completely as to impose with success upon his attendants; of which the following case, related by Dr. Haslam,[[534]] may serve as an excellent illustration. “A lunatic having received, or fancied he had received, an injury from his keeper, at the lunatic asylum at Manchester, threatened to be revenged, for which he was punished by confinement; he was afterwards a patient in Bethlem hospital, and gave Dr. Haslam an account of the transaction, of which the following is an abbreviation. ‘Not liking this situation, I was induced to play the hypocrite; I pretended extreme sorrow for having threatened him, and, by an affectation of repentance, induced him to release me; for several days I paid him great attention, and lent him every assistance; he seemed much pleased with the flattery, and became very friendly in his behaviour towards me; going one day into the kitchen, where his wife was busied, I saw a knife; this was too great a temptation to be resisted; I concealed it, and carried it about with me; for some time afterwards the same friendly intercourse was maintained between us, but as he was one day unlocking his garden door, I seized the opportunity and plunged this knife, up to the hilt, in his back.’” There is a species of insanity which has been called intermittent, in which the patient is perfectly rational for a considerable interval; the malady often recurs two or three times in a year, and lasts several weeks, the subject of the hallucination being always the same.[[535]]