- Email: [email protected]
ON MEDICO-LEGAL EVIDENCE IN CASES OF INSANITY.
76 "
It disposes," he says, " the person to acts of unkindness, and makes him the slave of every bad passion; it produces a fretfulness in all the daily and hourly intercourse of life ; it produces a domestic tyranny which brings, alas! with it a train of heartburnings and bitterness. This melancholy temper is poisonous to the happiness, not only of the individual, but of all that are the circle of its baneful influence." brought within Beattie’s 11 Minstrel" was one of those half-cracked, half-witted, sombre, clever, sullen, eccentric, melancholy youths; the type of thousands who are daily mixing in society, and whose condition might easily, upon a superficial examination, be confounded withwhose state of mind would certainly, by some, be insanity, and considered 11 unsound," should they be guilty of any ouert act of sufficient importance to call public and professional attention to their moral and legal responsibilty.
Lettsomian Lectures. No. III.
ON MEDICO-LEGAL EVIDENCE IN CASES OF INSANITY. BY FORBES WINSLOW, M.D., FELLOW OF ROY. COLL. PHYS. ED.; VICE-PRESIDENT AND LETTSOMIAN PROFESSOR OF MEDICINE OF THE MEDICAL SOCIETY OF LONDON FOR 1851-2, ETC. ETC.; EDITOR OF THE "JOURNAL OF PSYCHOLOGICAL MEDICINE."
PART II. Caution to be exercised in the use of the Plea of Insanity.The plea of insanity is one of the most important that can be urged in a court of justice in extenuation of crime. It should never be had recourse to except in clear and obvious cases, in which little or no doubt can be entertained, not only of the existence of mental derangement, but of derangement of such a ’,;ind, and to such a degree, as to justify the immediate admission
" Silent when glad ; affectionate, though shy; And now his look was most demurely sad, And now he laughed aloud, yet none knew why. The neighbours stared and sighed, yet bless’d the lad ; Some deemed him wondrous wise, and some believed him mad."
The Responsibility of the .z’.fedical Witness in Og,i,,7iizal Cases. —Icannot conceive a position of graver responsibility than that assumed by the medical witness when called upon in a court of the fact, and the necessary and consequent acquittal of the of justice to give evidence in criminal cases. Let me earnestly prisoner. The utmost vigilance and jealous caution should be entreat him, before discharging these solemn duties, to make exercised in all inquiries of this nature ; and medical men, himself master of all the facts of the case. He must not assume considered competent to the elucidation of such in- for granted the representations of those anxious to establish the tricate questions, should be particularly guarded in sanctioning, insanity of the criminal; if he do so, he will occasionally be by their authority, the plea of insanity, exhibiting, upon all occa- sadly deceived. He should never forget that he has a pttblic as sions, a fear lest their opinions should be made available for the well as a professional duty to discharge ; and he is bound, as a purposes of shielding great criminals from the just and legal citizen of the state, as well as a member of an important and penalties awarded for the commission of crime. learned section of society, to protect himself from the possibility The reflecting portion of the public and profession naturally , of being deceived as to the facts of any given case presented tQ place a high value upon the experience, testimony, and judgment him for his opinion. He must not permit his feelings to overof men whose peculiar studies and opportunities enable them to power and interfere with the free and unclouded operations of obtain a practical insight into the morbid phenomena of mind. his judgment. If it be found that men of position and ability are disposed to be Under these circumstances, every possible influence will occalax in the use of this important plea, a reaction will inevitably sionally be exercised to induce the witness to adopt an opinion ensue, and cases of this character will be left exclusively to the favourable to the prisoner. He will perceive the necessity of adjudication of the judge and jury, medical evidence being the case itself, and will not be satisfiedinvestigating entirely dispensed with. with one or two interivews with the alleged lunatic. He must Apparent deviations from normal conditions not to be con- obtain from the criminal an account of the act of which he may founded l1;ith Insanity.-In tbrming an opinion of the criminal as be charged, and his reasons for committing it; he will also well as the civil responsibility in any given case, it is very essential, acquire from his relatives, friends, and companions, an insight with the view of our arriving at right results, that we should into his former mode of life-his habits of thought, his prior make a just and scientific distinction between the actions of a state-the peculiarities of his disposition-whether there exists naturally eccentric, ill-regulated, perverse, and wicked mind, and an hereditary predisposition to insanity ; and other circumstances the mental disturbance, perverseness, caprice, vice, extravagance to elucidate the actual state of the mind at the time when of conduct, ungovernable passion, sullenness of disposition, and likely the alleged offence was perpetrated. Great perseverance and melancholia, consequent upon physical disease affecting the ingenuity are often required before the truth can be elicited. In integrity of the action of the brain. There is a normal these cases, the crimeis occasionally committed during aparoxysm and natural eccentricity, a healthy idiosyncrasy of thought, of transient insanitv; the mind manifesting no symptom of decaprice, and feeling,- distorted and perverted affection,- rangement after the perpetration of the offence. Again, a lunatic disposition to acts of cruelty, vice, brutality, quite inde- has been known to commit murder in a fit of frenzy, his sudden pendent of that irregularity and disturbance in the operations arrest and committal to prison temporarily restormg the mind to of the iratellect,-tleoseer°versions of the affections and madness of its healthy balance. A man has been guilty of a capital crime; conduct, the clear, unmistakable, and undoubted consequence of a has been seized and sent to prison, and has, from remorse, or a diseased mind. Asa man may have natural physical, so may sense of horror at his position, suddenly become insane; his he exhibit a connate mental defect, apart altogether from actual itself after his arrest. Personshave derangement only exhibiting cerebral, and consequent, mental disease. It should never be for- been known to commit the crime of murder whilst in a stsate of£ gotten that there is always floating upon the suriace of society a somnambulism, and also during that half-unconscious condition intemperate, eccentric persons, between sleeping and waking. Cases of this description are large body of strange, criminally and viciously disposed, subject to every bad passion, extremely perplexing to medical jurists. If it can be satisimpulsive in all their movements, addicted to habits of debauchery, factorily proved that the person perpetrated the murder whilst in who lead a kind of animal life; whose mode of existence appears this state-if the fact is unequivocally established-then, I confully to realize Lady Morgan’s somewhat illiberal conception of ceive, it ought to be considered as a good exculpating plea. It the character of the modern Italiansshould never, however, be forgotten, that these cases are easily simulated. Examples of this character are recorded by medical " Who eat, drink, and sleep. What then ? Who sleep, drink, and eat again. writers. A person has been suddenly roused by a frightful dream, whilst under its influence, has been known to take away There is a healthy and natural melancholy, and a diseased de- and, human life. Suicide has been committed under analogous cirof which is a drunkenness is of There species pression spirits. A person, apparently well, has gone to bed without cumstances. not insanity, and there is a form of derangement solely indicated the slightest tendency to self-destruction; he has manifesting habits of and uncontrollable inveterate intemperance. by awoke suddenly, and destroyed himself. A case, said to be illusThere is a brutality existing apart from lunacy, and there is a the effects trative of this, is related in a highly respectable and able medical violence of conduct, and cruelty of disposition, clearly It is as follows: "An old lady residing in London of a morbid mental condition. There is a natural, and, speakingjournal. awoke in the middle of the night, went down stairs, and threw as pathologists, a healthy improvidence, impetuosity of temper, herself into a cistern of water, where she was fouud drowned." and vice, which we must not confound with abnormal and disIt was maintained that the suicide was the result of certain eased states of the affections, passions, and propensities. The mental impressions conjured up in the mind during a dream. melancholia-the sullen gloom of real life (which is not "aliena- Dr. Pagan refers to the following interesting case, to prove that tion" of mind), is well described by an able metaphysician :*— murder may be committed by a person when under the effects of a frightful vision. * k Philosophy of the Human lIlínd, chap. on"Immediate Emotions." Dr. Bernard Schedmaizig suddenly woke at midnight; at the T. BuowxE.
specially
patiently
wayward,
-
.
’
’
77 moment he
frightful phantom, or what his imagination such-a fearful spectre! He twice called out, "Who is that?" He received no answer. Imagining that the phantom was advancing upon him, and having altogether lost his self-possession, he raised a hatchet which was beside him, and attacked the spectre: it was found that he had murdered his wife! " A pedlar, who was in the hahit of walking about the country armed with a sword-stick, was awakened one evening, while saw a
whether the disease
so
designated is purely
an
affection of
the
and whether, as metaphysicians, we arejustined in drawing so palpable a line of separation and demarcation between those faculties of the understanding that reason, judge. compare, reflect, and those that supply motives to the reason, and are termed, by metaphysicians, the active principles of the mind ? Viewing the question under review pathologically,ask whether, in those cases of insanity which are represented to consist in lesions of the will-in ungovernable impetuosity of temper-loss lying asleep on the high road, by a man suddenly seizing him, of self-control-perversion of the affections and propensities-cases and shaking him by the shoulders. The man, who was walking in which the mental alienation is manifested more in conduct than in by with some companions, had done this out of a joke. The ideas-where the delirium is confined to the actions and moral senin this form of mental derangement, the intelpedlar suddenly woke, drew his sword, and stabbed the man, who
represented
as
moral,faculties;
My betief
guilty."*
unhappily tle
pursuing
brilliancy
punishment,
imagination,
insanity ;"
specltic
until
*
British and Foreign Medical Review.
one
smelt the
day in the author’s presence he confessed that he tasted and delicious fruit on the walls.-(p. 119.)
most
78 whilst another, as memory or imagination, is diseased; but that admit that such manifestations are only different 1nodes or the mind is sound when reflecting upon its own operations, and of development of one and t7te same principle; that the diseased when exercising the combination termed imagination, life that manifests itself through the brain, the lungs, the stomach, or casting the retrospect called reflection." Then again, as to heart, is identical and homogeneous in its nature and essence; what is termed impulsive insanity, a form of disease generally the peculiarity of the organization affecting, as it undoubtedly considered to be associated with derangement of the ideas, I does, its mode of being or action. Applying this metaphysical would ask, is it A fact that these cases are invariably unaccom- doctrine to the subject now under consideration, it must be evident panied by delusive impressions, or by a disturbance of the reason- to us, that in all the varied phenomena of insanity the same ing faculties? Admitting the existence of a morbid impulsive identical essence or principle is affected; that, without any expropensity, does it become absolutely irresistible and uncon. ceptions, THE MIND—using this term in its truly liberal and philotrollable except during a crisis of delirium? It has been main- sophical signification-is in a state of disorder. In saying thus tained, that at the moment of the impalsion an intellectual per- much, I would protect myself from the supposition that I repudiate turbation and positive derangement of ideas occurs. "Webelieve," the great discovery of Gall, or that I hold, with the spiritualists, " says one French writer, that the doctrine of a temporary insanity, that the principle of thought is susceptible of actual disease, apart of a sudden eclipse of the reason at the time of the act, is a safer from any abnormal state of the cerebral tissue. In aU cases of and more philosophical doctrine than the hypothesis of modern mental derangement, the manifestations of the mind, and not the medical jurists, who assert that no monomania, whether homicidal, mind itself, are implicated; or, to speak with a strict regard to suicidal, or incendiary, can compel to the consummation of the the principles of pathological science, the pitysical media, or act, without insanity in the ordinary acceptation of the term, or different portions of nervous matter through which the intellect intellectual disturbance. We repeat that we cannot admit this operates, are diseased, and, as a necessary consequence, the printheory or principle of monomania with irresistible desire, and ciple developed through the material instrument of the mind is without delirium during the act, because it appears to us to be disordered or deranged in its operations. As there appears a dangerous, inasmuch as it suspends the course of free-will, is de- determination to repudiate, in the courts of law, the termmoral structive of the morality of human actions, and tends to favour insanity," I would advise the witness to avoid, upon all occaimpunity for crimes. For if the impulse be irresistible, and is sions, an ostentatious and unnecessary use of the phrase. If unaccompanied by delirium during the act, what becomes then of called upon to give evidence in cases of insanityapparently infree-will ? In our minds, the disturbance of the reason will always volving exclusively the healthy action of the affective powers, I be more comprehensible and conformable to the common-sense of would recommend the witness, when asked to state his opinion of the condition of the mind and the degree of responsibility in cases mankind than a perversion of the will without delirium." 1110ral Insanity meiaphysically analyzed.-Having considered of this nature, to speak of the disorderasone implicating the healthy this matter pathologically, I would briefly analyze the question action of the mental principle. In reply to the interrogatoryIn using the " Do you consider the prisoner at the bar of sound mind, and a at issue in relation to its metaphysical aspect. words "mind," "intellect," "understanding," we employ abstract responsible agent ?"-I would suggest to the witness the safety terms to denote an aggregate condition of all the phenomena of of answering, to the best of his judgment, either affirmatively or intelligence, to describe the manifestations of one and an indivisible negatively ; bearing always in recollection, that in all phases and essence-a principle homogeneous in its character. In classifying, degrees of insanity, whatever form it may assume, one and the for the convenience of philosophical investigation, the mind into same essence is involved in the disturbance-that all are, strictly separate and distinct powers or faculties, emotions or passions, speaking, MENTAL AFFECTIONS. are we not forgetful of the fact, that this arrangement, classificaLaw of Lunacy in relation to Testamentary Disposit1’ons of tion, order, division, and subdivision, are entirely of an arbitrary Property.-I purposely decline entering at any length into the character, and that in reality the principle, essence, and sub- consideration of the law of lunacy relating to dispositions of stratum of the mind, whatever it may be, is in itself a unit, and property, and the performance of the marriage contract. In the incapable, by virtue of its existence, of being subjected to such a former case, the proof of insanity invalidates all testamentary division and classification. Many of the so-termed faculties of documents; but the courts are extremely jealous in interfering the mind, the emotions and passions, which are spoken of as in- with the apparent wishes of the testator, unless clear and positive and distinct powers, are obviously only modifications lunacy be established. The character of the testamentary docuof; or different modes of being or manifestations of, one particular ment itself is generally viewed as the most important evidence mental condition or state of intellectual relation. " We cannot of the capacity of the attesting party. Parties actually in conmap out the mind as we can a country or a county, assigning to finement, and so violent as occasionally to require the application each town, province, or state, its separate controlling and free of mechanical restraint, have executed wills, and such wills have sovereignty. We are not justified in converting each faculty into been declared valid and operative in the prerogative court; the a little independent mind,’ as if the original mind were like that principle of law being, that the testccmerat itself exhibited, primâ of the polypus, which, according to naturalists, may be cut into facie, no evidence of mental derangement. If the will should be an almost infinite number of parts, each of which becomes a such a will that a sane and rational man would make-the propolypus as perfect as that from which it was separated."** ,I perty descending in the right and legitimate channel—the suspect," says Locke, "that this way of speaking of the faculties court will not easily be induced to set it aside, even if a conhas misled many into a confused notion of so many distinct siderable amount of eccentricity, oddity, and even insanity, agents in us, which had their several provinces, and did com- have existed. The proof of eccentricity to an extreme degree, mand, obey, and perform several actions as so many distinct even if accompanied by a testamentary disposition contrary to beings ; which has been no small occasion of wrangling, obscurity, the usual order of succession, is not sufficient to induce the and uncertainty, in questions relating to them." " The mind," says Ecclesiastical Court to pronounce a will invalid. The following another eminent authority, "is formed susceptible of certain affec- remarkable case of Morgan v. Boys is one in point :The testator in this instance died, leaving by his will a large tions ; these states or affections we may generalize more or less, and, according to our generalization, may give them more or fortune to his housekeeper. The will was disputed by his relafewer names. But," he continues,"whatever maybe the extent of tives on the ground that it bore intrinsic evidence of his not having been ina sane state of mind. After having bequeathed his property, our vocabulary, the mind itself is as independent of these transient designations as He who fixed its constitution-still continues to the deceased directed that his executors should cause some part exhibit the same unaltered susceptibilities which it originally re- of his bowels to be converted into fiddle-strings, that others should ceived; as the flowers which the same Divine Author formed, be sublimed into smelling salts, and that the remainder of his spring up in the same manner, observing the same seasons, and body should be vitrified into lenses for optical purposes !He spreading to the sun the same foliage and blossoms, whatever be further added in a letter, " the world may think this done in a the systems and the corresponding nomenclature, according to spirit of singularity or a whim;" but he expressed himself as a moral aversion to funeral pomp, and he wished his body which the botanists may have agreed to record and name their tribes. The great Preserver of Nature has not trusted us with to be converted to purposes useful to mankind. Sir Herbert the dangerous power of altering a single physical law which He Jenner Fust, in giving judgment, held that insanity was not has established, though he has given us unlimited power over the proved ; the fact merely amounted to eccentricity, and on this language which is of our own creation:’ May we not apply the ground he pronounced in favour of the will. It was proved that same argument to the phenomena of life ? We observe the prin- the testator had conducted his affairs with great shrewdness and ciples of vitality manifested through different physical media; ability; that he not only did not labour under imbecility of mind, but whatever may be the character of the material tissue, but that he was treated as a person of indisputable capacity by those with whom he had to deal. or the special functions of the organic structure through In these cases the medical man has to give evidence as to the which life exhibits its powers, we, as spiritual physiologists, existence of what in legal phraseology is termed a lucid interval’’ Without entering into a psychological or pathological considerBrowne.
states the
’
dependent
having
-
79
opposition which applies to this measure, in the latter cases’ have had opportunities of studying insanity, must readily admit, must apply to the former; so that it is absolutely unreasonablethat during attacks of mental derangement, the mind does occaTracheotomy "cures" no disease. It averts present and sionally become apparently free from diseased impressions-at future danger in many. In epilepsy, when that disease least, from all obvious and appreciable delusions, and is quite assumes the form of epilepsia laryngea, it changes, modifies, competent at these periods, or " lucid intervals," to the exercise and mitigates the disease by averting the effects of its larynof a right judgment in relation to the disposal of property. gismus and its direst form, and may lead, under judicious The Law of Lunacy in relation to Marriage.—With regard to management, to its cessation entirely, in the place of its tranthe legal bearing of this subject upon the question of marriage, it sition into loss of life, of intellect, or limb ! must be obvious that insanity " must invalidate the most imAs it will not cure epilepsy, far less will it cure any compliportant contract of life, the very essence of which is consent." cation of epilepsy. In one case there had been a paralytic The spiritual court has the sole and exclusive cognizance of attack; in another there was fatty degeneration of the heart. questioning and deciding directly the legality of marriage, and of What effect could tracheotomy be imagined to possess in such enforcing specifically the right and obligations respecting persons cases ? If the case be hereditary; if it be inveterate; if organic depending upon it. But the temporal courts have the sole cognizance of examining and deciding upon all temporal rights of change has already occurred; if, with attacks of epilepsia property ; and so far as such rights are concerned, they have the i laryngea, there are attacks of epilepsy in its milder or mildest inherent right of deciding incidentally either upon the fact or forms, who does not perceive what, and what degree of, benefit may be justly expected from tracheotomy? legality of marriage.** In cases of pure and uncomplicated epilepsia laryngea, the In cases of disputed wills, on the ground of mental incompetency, the evidence of the medical witness is generally recorded seizures, under the influence of tracheotomy, become, how(privately) before a proctor or his representative. The witness ever, impossible. These seizures may still subsist in a mitihas to reply to a series of written interrogatories relating to the gated form; but seizures of epilepsia laryngea they cannot be! testator’s state of mind, and his replies are written at length by a They cannot assume the direst form, followed by the direst person specially deputed to examine him, and take his evidence. consequences of epilepsy! To what degree the mitigation of this dire disease may proThe cross-examination is also conducted upon the same principle, and the evidence thus recorded, after being attested upon ceed, and whether it may cease altogether, in the absence of oath, is adduced in court during the trial. In attempts to invali- its severest form, time and experience only can determine. date the marriage contract upon the ground of insanity, the in- That many splendid recoveries or cures will take place, from quiry is in some cases of the nature of an ordinary commission ofF the just institution of this remedy, life, intellect, and limb lunacy. Should the lunacy be thus established, the subsequentt being preserved, I am persuaded. That many disappointments question of divorce must of necessity come before the Ecclesias- will result from its injudicious employment, in inveterate cases tical Court. It is not, however, indispensable that in these cases -in cases already complicated with organic lesion-in cases of faulty diagnosis, is equally certain. a writ de lunatico inquirendo should issue. To revert to my first proposition. Tracheotomy averts the effects of laryngismus. This is its special and exclusive office in every case in which it is employed, and not in epilepsy alone. The same reasoning applies to all, and epilepsy presents no CLINICAL NOTES. exception to the rule. BY MARSHALL HALL, M.D., F.R.S., &c. Once more, then, I repeat-The office of tracheotomy is to avert the effects and consequences, immediate and remote, of (Communicated by J. RUSSELL REYNOLDS, M.D.)
ation of this vexata quæstio, I will only observe, that all who
.
.
.
-
laryngismus.
NOTE XII.—ON LARYNGISMUS,
AND ON
-
EPILEPSIA LARYNGEA
I trust it will not again be asserted that tracheotomy has AND TRACHEOTOMY. been proposed as a cure for epilepsy. Tracheotomy is, in fact, TRACHEOTOMY is the preventive of the effects of laryngismus. a cure for no disease. In laryngitis, in which it is used, it averts the immediate danger to life, and affords time and It can effect no more: it can do no less. In whatever malady laryngismus occurs, whether it assume opportunity for remedies. In epilepsy, in which it never the paralytic form, as in inorganic apoplexy, or the spasmodic, before was used, it does more; it averts the immediate and the remote dangers to life and intellect and limb; it renders as in inorganic epilepsy, this is the office of tracheotomy; the attack abortive, reducing it from the graver to a milder the effects of this laryngismus are, and must be, obviated. It is not therefore for apoplexy, or epilepsy, or tetanus, or form, affording time and opportunity for remedies, and for the -any other disease, that tracheotomy can be recommended; but gradual subsidence of augmented excitability of the spinal whenever such disease assumes the laryngeal form, laryngismus centre, and of the susceptibility to attacks, excited and left by being superadded to the other symptoms, and becoming the the disease in its unmitigated form. especial source of danger, then tracheotomy averts this .
danger!
The disease is thus made to assume a modified, or, it may be called the abortive, form. Its character is mitigated; its tendency, whether this be to apoplexy, to mania, to asphyxia, is prevented. Apoplexy and epilepsy cease to be the apoplexia and the epilepsia laryngea. Life and intellect may be preserved. Let the reader look over the arrangement in THE LANCET of Nov. 13, 1852, and he will perceive that this is, not in - epilepsy only, but in every case, the object, the effect of tracheotomy. In laryngitis, tracheotomy averts the impending danger to life, and gives the opportunity for the use of remedies for removing the original disease. In the case of a foreign body in the trachea, tracheotomy may lead to its extraction by the orifice. But this is an exception to the rule, and tracheotomy is no more to be expected to cure apoplexy or epilepsy than to cure laryngitis. Its influence is to modify and mitigate their severest form, converting the apoplexia laryngea and epilepsia laryngea into the apoplexia trachelea and epilepsia trachelea, which may indeed still be severe, but which generally assume a mild and fading form, with far less dire effects and consequences, immediate and remote. And again, space is offered for the use of remedies. The same motive which urges to the institution of tracheotomy in laryngitis, must urge us to its institution in the apoplexia laryngea, and the epilepsia laryngea, &c. ; and the same * Starkie
on
Ev.
In
one
trachea;
case, that of Mr. Cane, the tube is still worn in the seizure of any kind has occurred during twenty-
no
three months, although they had formerly occurred in their worst form, on an average, every third day. In a second, that of Mr. Mackarsie, there has recently been the threatening of a return of paralysis, experienced once, unknown to me, formerly. It is to be feared, therefore, that there may be organic disease. Still the operation has effected all that it can effect in any case; it has, as it ever must do, averted the effects 3 of laryngismus, and changed the form of the disease from the laryngeal to the tracheleal. In the third case, or that of Mr. Anderson, the same good effect was produced; but the patient has died with fatty degeneration of the heart. It will be remembered that the poor woman’s father was epileptic; that she had been afflicted during twenty-four years out of thirty-six, which was her age. She was of the frailest form, pale and thin, and of leaden aspect; she had minor attacks after the graver had been obviated, and she either died from epilepsia syncopalis, or from syncope arising from the affection of the heart. On a post-mortem examination, it was found that though the tracheal tube had been worn during many months, no inflammation had extended along the internal membrane of the trachea. ____
I will now beg my reader again to revert to the classification cases in which tracheotomy may be required, given in THE
! of
It disposes," he says, " the person to acts of unkindness, and makes him the slave of every bad passion; it produces a fretfulness in all the daily and hourly intercourse of life ; it produces a domestic tyranny which brings, alas! with it a train of heartburnings and bitterness. This melancholy temper is poisonous to the happiness, not only of the individual, but of all that are the circle of its baneful influence." brought within Beattie’s 11 Minstrel" was one of those half-cracked, half-witted, sombre, clever, sullen, eccentric, melancholy youths; the type of thousands who are daily mixing in society, and whose condition might easily, upon a superficial examination, be confounded withwhose state of mind would certainly, by some, be insanity, and considered 11 unsound," should they be guilty of any ouert act of sufficient importance to call public and professional attention to their moral and legal responsibilty.
Lettsomian Lectures. No. III.
ON MEDICO-LEGAL EVIDENCE IN CASES OF INSANITY. BY FORBES WINSLOW, M.D., FELLOW OF ROY. COLL. PHYS. ED.; VICE-PRESIDENT AND LETTSOMIAN PROFESSOR OF MEDICINE OF THE MEDICAL SOCIETY OF LONDON FOR 1851-2, ETC. ETC.; EDITOR OF THE "JOURNAL OF PSYCHOLOGICAL MEDICINE."
PART II. Caution to be exercised in the use of the Plea of Insanity.The plea of insanity is one of the most important that can be urged in a court of justice in extenuation of crime. It should never be had recourse to except in clear and obvious cases, in which little or no doubt can be entertained, not only of the existence of mental derangement, but of derangement of such a ’,;ind, and to such a degree, as to justify the immediate admission
" Silent when glad ; affectionate, though shy; And now his look was most demurely sad, And now he laughed aloud, yet none knew why. The neighbours stared and sighed, yet bless’d the lad ; Some deemed him wondrous wise, and some believed him mad."
The Responsibility of the .z’.fedical Witness in Og,i,,7iizal Cases. —Icannot conceive a position of graver responsibility than that assumed by the medical witness when called upon in a court of the fact, and the necessary and consequent acquittal of the of justice to give evidence in criminal cases. Let me earnestly prisoner. The utmost vigilance and jealous caution should be entreat him, before discharging these solemn duties, to make exercised in all inquiries of this nature ; and medical men, himself master of all the facts of the case. He must not assume considered competent to the elucidation of such in- for granted the representations of those anxious to establish the tricate questions, should be particularly guarded in sanctioning, insanity of the criminal; if he do so, he will occasionally be by their authority, the plea of insanity, exhibiting, upon all occa- sadly deceived. He should never forget that he has a pttblic as sions, a fear lest their opinions should be made available for the well as a professional duty to discharge ; and he is bound, as a purposes of shielding great criminals from the just and legal citizen of the state, as well as a member of an important and penalties awarded for the commission of crime. learned section of society, to protect himself from the possibility The reflecting portion of the public and profession naturally , of being deceived as to the facts of any given case presented tQ place a high value upon the experience, testimony, and judgment him for his opinion. He must not permit his feelings to overof men whose peculiar studies and opportunities enable them to power and interfere with the free and unclouded operations of obtain a practical insight into the morbid phenomena of mind. his judgment. If it be found that men of position and ability are disposed to be Under these circumstances, every possible influence will occalax in the use of this important plea, a reaction will inevitably sionally be exercised to induce the witness to adopt an opinion ensue, and cases of this character will be left exclusively to the favourable to the prisoner. He will perceive the necessity of adjudication of the judge and jury, medical evidence being the case itself, and will not be satisfiedinvestigating entirely dispensed with. with one or two interivews with the alleged lunatic. He must Apparent deviations from normal conditions not to be con- obtain from the criminal an account of the act of which he may founded l1;ith Insanity.-In tbrming an opinion of the criminal as be charged, and his reasons for committing it; he will also well as the civil responsibility in any given case, it is very essential, acquire from his relatives, friends, and companions, an insight with the view of our arriving at right results, that we should into his former mode of life-his habits of thought, his prior make a just and scientific distinction between the actions of a state-the peculiarities of his disposition-whether there exists naturally eccentric, ill-regulated, perverse, and wicked mind, and an hereditary predisposition to insanity ; and other circumstances the mental disturbance, perverseness, caprice, vice, extravagance to elucidate the actual state of the mind at the time when of conduct, ungovernable passion, sullenness of disposition, and likely the alleged offence was perpetrated. Great perseverance and melancholia, consequent upon physical disease affecting the ingenuity are often required before the truth can be elicited. In integrity of the action of the brain. There is a normal these cases, the crimeis occasionally committed during aparoxysm and natural eccentricity, a healthy idiosyncrasy of thought, of transient insanitv; the mind manifesting no symptom of decaprice, and feeling,- distorted and perverted affection,- rangement after the perpetration of the offence. Again, a lunatic disposition to acts of cruelty, vice, brutality, quite inde- has been known to commit murder in a fit of frenzy, his sudden pendent of that irregularity and disturbance in the operations arrest and committal to prison temporarily restormg the mind to of the iratellect,-tleoseer°versions of the affections and madness of its healthy balance. A man has been guilty of a capital crime; conduct, the clear, unmistakable, and undoubted consequence of a has been seized and sent to prison, and has, from remorse, or a diseased mind. Asa man may have natural physical, so may sense of horror at his position, suddenly become insane; his he exhibit a connate mental defect, apart altogether from actual itself after his arrest. Personshave derangement only exhibiting cerebral, and consequent, mental disease. It should never be for- been known to commit the crime of murder whilst in a stsate of£ gotten that there is always floating upon the suriace of society a somnambulism, and also during that half-unconscious condition intemperate, eccentric persons, between sleeping and waking. Cases of this description are large body of strange, criminally and viciously disposed, subject to every bad passion, extremely perplexing to medical jurists. If it can be satisimpulsive in all their movements, addicted to habits of debauchery, factorily proved that the person perpetrated the murder whilst in who lead a kind of animal life; whose mode of existence appears this state-if the fact is unequivocally established-then, I confully to realize Lady Morgan’s somewhat illiberal conception of ceive, it ought to be considered as a good exculpating plea. It the character of the modern Italiansshould never, however, be forgotten, that these cases are easily simulated. Examples of this character are recorded by medical " Who eat, drink, and sleep. What then ? Who sleep, drink, and eat again. writers. A person has been suddenly roused by a frightful dream, whilst under its influence, has been known to take away There is a healthy and natural melancholy, and a diseased de- and, human life. Suicide has been committed under analogous cirof which is a drunkenness is of There species pression spirits. A person, apparently well, has gone to bed without cumstances. not insanity, and there is a form of derangement solely indicated the slightest tendency to self-destruction; he has manifesting habits of and uncontrollable inveterate intemperance. by awoke suddenly, and destroyed himself. A case, said to be illusThere is a brutality existing apart from lunacy, and there is a the effects trative of this, is related in a highly respectable and able medical violence of conduct, and cruelty of disposition, clearly It is as follows: "An old lady residing in London of a morbid mental condition. There is a natural, and, speakingjournal. awoke in the middle of the night, went down stairs, and threw as pathologists, a healthy improvidence, impetuosity of temper, herself into a cistern of water, where she was fouud drowned." and vice, which we must not confound with abnormal and disIt was maintained that the suicide was the result of certain eased states of the affections, passions, and propensities. The mental impressions conjured up in the mind during a dream. melancholia-the sullen gloom of real life (which is not "aliena- Dr. Pagan refers to the following interesting case, to prove that tion" of mind), is well described by an able metaphysician :*— murder may be committed by a person when under the effects of a frightful vision. * k Philosophy of the Human lIlínd, chap. on"Immediate Emotions." Dr. Bernard Schedmaizig suddenly woke at midnight; at the T. BuowxE.
specially
patiently
wayward,
-
.
’
’
77 moment he
frightful phantom, or what his imagination such-a fearful spectre! He twice called out, "Who is that?" He received no answer. Imagining that the phantom was advancing upon him, and having altogether lost his self-possession, he raised a hatchet which was beside him, and attacked the spectre: it was found that he had murdered his wife! " A pedlar, who was in the hahit of walking about the country armed with a sword-stick, was awakened one evening, while saw a
whether the disease
so
designated is purely
an
affection of
the
and whether, as metaphysicians, we arejustined in drawing so palpable a line of separation and demarcation between those faculties of the understanding that reason, judge. compare, reflect, and those that supply motives to the reason, and are termed, by metaphysicians, the active principles of the mind ? Viewing the question under review pathologically,ask whether, in those cases of insanity which are represented to consist in lesions of the will-in ungovernable impetuosity of temper-loss lying asleep on the high road, by a man suddenly seizing him, of self-control-perversion of the affections and propensities-cases and shaking him by the shoulders. The man, who was walking in which the mental alienation is manifested more in conduct than in by with some companions, had done this out of a joke. The ideas-where the delirium is confined to the actions and moral senin this form of mental derangement, the intelpedlar suddenly woke, drew his sword, and stabbed the man, who
represented
as
moral,faculties;
My betief
guilty."*
unhappily tle
pursuing
brilliancy
punishment,
imagination,
insanity ;"
specltic
until
*
British and Foreign Medical Review.
one
smelt the
day in the author’s presence he confessed that he tasted and delicious fruit on the walls.-(p. 119.)
most
78 whilst another, as memory or imagination, is diseased; but that admit that such manifestations are only different 1nodes or the mind is sound when reflecting upon its own operations, and of development of one and t7te same principle; that the diseased when exercising the combination termed imagination, life that manifests itself through the brain, the lungs, the stomach, or casting the retrospect called reflection." Then again, as to heart, is identical and homogeneous in its nature and essence; what is termed impulsive insanity, a form of disease generally the peculiarity of the organization affecting, as it undoubtedly considered to be associated with derangement of the ideas, I does, its mode of being or action. Applying this metaphysical would ask, is it A fact that these cases are invariably unaccom- doctrine to the subject now under consideration, it must be evident panied by delusive impressions, or by a disturbance of the reason- to us, that in all the varied phenomena of insanity the same ing faculties? Admitting the existence of a morbid impulsive identical essence or principle is affected; that, without any expropensity, does it become absolutely irresistible and uncon. ceptions, THE MIND—using this term in its truly liberal and philotrollable except during a crisis of delirium? It has been main- sophical signification-is in a state of disorder. In saying thus tained, that at the moment of the impalsion an intellectual per- much, I would protect myself from the supposition that I repudiate turbation and positive derangement of ideas occurs. "Webelieve," the great discovery of Gall, or that I hold, with the spiritualists, " says one French writer, that the doctrine of a temporary insanity, that the principle of thought is susceptible of actual disease, apart of a sudden eclipse of the reason at the time of the act, is a safer from any abnormal state of the cerebral tissue. In aU cases of and more philosophical doctrine than the hypothesis of modern mental derangement, the manifestations of the mind, and not the medical jurists, who assert that no monomania, whether homicidal, mind itself, are implicated; or, to speak with a strict regard to suicidal, or incendiary, can compel to the consummation of the the principles of pathological science, the pitysical media, or act, without insanity in the ordinary acceptation of the term, or different portions of nervous matter through which the intellect intellectual disturbance. We repeat that we cannot admit this operates, are diseased, and, as a necessary consequence, the printheory or principle of monomania with irresistible desire, and ciple developed through the material instrument of the mind is without delirium during the act, because it appears to us to be disordered or deranged in its operations. As there appears a dangerous, inasmuch as it suspends the course of free-will, is de- determination to repudiate, in the courts of law, the termmoral structive of the morality of human actions, and tends to favour insanity," I would advise the witness to avoid, upon all occaimpunity for crimes. For if the impulse be irresistible, and is sions, an ostentatious and unnecessary use of the phrase. If unaccompanied by delirium during the act, what becomes then of called upon to give evidence in cases of insanityapparently infree-will ? In our minds, the disturbance of the reason will always volving exclusively the healthy action of the affective powers, I be more comprehensible and conformable to the common-sense of would recommend the witness, when asked to state his opinion of the condition of the mind and the degree of responsibility in cases mankind than a perversion of the will without delirium." 1110ral Insanity meiaphysically analyzed.-Having considered of this nature, to speak of the disorderasone implicating the healthy this matter pathologically, I would briefly analyze the question action of the mental principle. In reply to the interrogatoryIn using the " Do you consider the prisoner at the bar of sound mind, and a at issue in relation to its metaphysical aspect. words "mind," "intellect," "understanding," we employ abstract responsible agent ?"-I would suggest to the witness the safety terms to denote an aggregate condition of all the phenomena of of answering, to the best of his judgment, either affirmatively or intelligence, to describe the manifestations of one and an indivisible negatively ; bearing always in recollection, that in all phases and essence-a principle homogeneous in its character. In classifying, degrees of insanity, whatever form it may assume, one and the for the convenience of philosophical investigation, the mind into same essence is involved in the disturbance-that all are, strictly separate and distinct powers or faculties, emotions or passions, speaking, MENTAL AFFECTIONS. are we not forgetful of the fact, that this arrangement, classificaLaw of Lunacy in relation to Testamentary Disposit1’ons of tion, order, division, and subdivision, are entirely of an arbitrary Property.-I purposely decline entering at any length into the character, and that in reality the principle, essence, and sub- consideration of the law of lunacy relating to dispositions of stratum of the mind, whatever it may be, is in itself a unit, and property, and the performance of the marriage contract. In the incapable, by virtue of its existence, of being subjected to such a former case, the proof of insanity invalidates all testamentary division and classification. Many of the so-termed faculties of documents; but the courts are extremely jealous in interfering the mind, the emotions and passions, which are spoken of as in- with the apparent wishes of the testator, unless clear and positive and distinct powers, are obviously only modifications lunacy be established. The character of the testamentary docuof; or different modes of being or manifestations of, one particular ment itself is generally viewed as the most important evidence mental condition or state of intellectual relation. " We cannot of the capacity of the attesting party. Parties actually in conmap out the mind as we can a country or a county, assigning to finement, and so violent as occasionally to require the application each town, province, or state, its separate controlling and free of mechanical restraint, have executed wills, and such wills have sovereignty. We are not justified in converting each faculty into been declared valid and operative in the prerogative court; the a little independent mind,’ as if the original mind were like that principle of law being, that the testccmerat itself exhibited, primâ of the polypus, which, according to naturalists, may be cut into facie, no evidence of mental derangement. If the will should be an almost infinite number of parts, each of which becomes a such a will that a sane and rational man would make-the propolypus as perfect as that from which it was separated."** ,I perty descending in the right and legitimate channel—the suspect," says Locke, "that this way of speaking of the faculties court will not easily be induced to set it aside, even if a conhas misled many into a confused notion of so many distinct siderable amount of eccentricity, oddity, and even insanity, agents in us, which had their several provinces, and did com- have existed. The proof of eccentricity to an extreme degree, mand, obey, and perform several actions as so many distinct even if accompanied by a testamentary disposition contrary to beings ; which has been no small occasion of wrangling, obscurity, the usual order of succession, is not sufficient to induce the and uncertainty, in questions relating to them." " The mind," says Ecclesiastical Court to pronounce a will invalid. The following another eminent authority, "is formed susceptible of certain affec- remarkable case of Morgan v. Boys is one in point :The testator in this instance died, leaving by his will a large tions ; these states or affections we may generalize more or less, and, according to our generalization, may give them more or fortune to his housekeeper. The will was disputed by his relafewer names. But," he continues,"whatever maybe the extent of tives on the ground that it bore intrinsic evidence of his not having been ina sane state of mind. After having bequeathed his property, our vocabulary, the mind itself is as independent of these transient designations as He who fixed its constitution-still continues to the deceased directed that his executors should cause some part exhibit the same unaltered susceptibilities which it originally re- of his bowels to be converted into fiddle-strings, that others should ceived; as the flowers which the same Divine Author formed, be sublimed into smelling salts, and that the remainder of his spring up in the same manner, observing the same seasons, and body should be vitrified into lenses for optical purposes !He spreading to the sun the same foliage and blossoms, whatever be further added in a letter, " the world may think this done in a the systems and the corresponding nomenclature, according to spirit of singularity or a whim;" but he expressed himself as a moral aversion to funeral pomp, and he wished his body which the botanists may have agreed to record and name their tribes. The great Preserver of Nature has not trusted us with to be converted to purposes useful to mankind. Sir Herbert the dangerous power of altering a single physical law which He Jenner Fust, in giving judgment, held that insanity was not has established, though he has given us unlimited power over the proved ; the fact merely amounted to eccentricity, and on this language which is of our own creation:’ May we not apply the ground he pronounced in favour of the will. It was proved that same argument to the phenomena of life ? We observe the prin- the testator had conducted his affairs with great shrewdness and ciples of vitality manifested through different physical media; ability; that he not only did not labour under imbecility of mind, but whatever may be the character of the material tissue, but that he was treated as a person of indisputable capacity by those with whom he had to deal. or the special functions of the organic structure through In these cases the medical man has to give evidence as to the which life exhibits its powers, we, as spiritual physiologists, existence of what in legal phraseology is termed a lucid interval’’ Without entering into a psychological or pathological considerBrowne.
states the
’
dependent
having
-
79
opposition which applies to this measure, in the latter cases’ have had opportunities of studying insanity, must readily admit, must apply to the former; so that it is absolutely unreasonablethat during attacks of mental derangement, the mind does occaTracheotomy "cures" no disease. It averts present and sionally become apparently free from diseased impressions-at future danger in many. In epilepsy, when that disease least, from all obvious and appreciable delusions, and is quite assumes the form of epilepsia laryngea, it changes, modifies, competent at these periods, or " lucid intervals," to the exercise and mitigates the disease by averting the effects of its larynof a right judgment in relation to the disposal of property. gismus and its direst form, and may lead, under judicious The Law of Lunacy in relation to Marriage.—With regard to management, to its cessation entirely, in the place of its tranthe legal bearing of this subject upon the question of marriage, it sition into loss of life, of intellect, or limb ! must be obvious that insanity " must invalidate the most imAs it will not cure epilepsy, far less will it cure any compliportant contract of life, the very essence of which is consent." cation of epilepsy. In one case there had been a paralytic The spiritual court has the sole and exclusive cognizance of attack; in another there was fatty degeneration of the heart. questioning and deciding directly the legality of marriage, and of What effect could tracheotomy be imagined to possess in such enforcing specifically the right and obligations respecting persons cases ? If the case be hereditary; if it be inveterate; if organic depending upon it. But the temporal courts have the sole cognizance of examining and deciding upon all temporal rights of change has already occurred; if, with attacks of epilepsia property ; and so far as such rights are concerned, they have the i laryngea, there are attacks of epilepsy in its milder or mildest inherent right of deciding incidentally either upon the fact or forms, who does not perceive what, and what degree of, benefit may be justly expected from tracheotomy? legality of marriage.** In cases of pure and uncomplicated epilepsia laryngea, the In cases of disputed wills, on the ground of mental incompetency, the evidence of the medical witness is generally recorded seizures, under the influence of tracheotomy, become, how(privately) before a proctor or his representative. The witness ever, impossible. These seizures may still subsist in a mitihas to reply to a series of written interrogatories relating to the gated form; but seizures of epilepsia laryngea they cannot be! testator’s state of mind, and his replies are written at length by a They cannot assume the direst form, followed by the direst person specially deputed to examine him, and take his evidence. consequences of epilepsy! To what degree the mitigation of this dire disease may proThe cross-examination is also conducted upon the same principle, and the evidence thus recorded, after being attested upon ceed, and whether it may cease altogether, in the absence of oath, is adduced in court during the trial. In attempts to invali- its severest form, time and experience only can determine. date the marriage contract upon the ground of insanity, the in- That many splendid recoveries or cures will take place, from quiry is in some cases of the nature of an ordinary commission ofF the just institution of this remedy, life, intellect, and limb lunacy. Should the lunacy be thus established, the subsequentt being preserved, I am persuaded. That many disappointments question of divorce must of necessity come before the Ecclesias- will result from its injudicious employment, in inveterate cases tical Court. It is not, however, indispensable that in these cases -in cases already complicated with organic lesion-in cases of faulty diagnosis, is equally certain. a writ de lunatico inquirendo should issue. To revert to my first proposition. Tracheotomy averts the effects of laryngismus. This is its special and exclusive office in every case in which it is employed, and not in epilepsy alone. The same reasoning applies to all, and epilepsy presents no CLINICAL NOTES. exception to the rule. BY MARSHALL HALL, M.D., F.R.S., &c. Once more, then, I repeat-The office of tracheotomy is to avert the effects and consequences, immediate and remote, of (Communicated by J. RUSSELL REYNOLDS, M.D.)
ation of this vexata quæstio, I will only observe, that all who
.
.
.
-
laryngismus.
NOTE XII.—ON LARYNGISMUS,
AND ON
-
EPILEPSIA LARYNGEA
I trust it will not again be asserted that tracheotomy has AND TRACHEOTOMY. been proposed as a cure for epilepsy. Tracheotomy is, in fact, TRACHEOTOMY is the preventive of the effects of laryngismus. a cure for no disease. In laryngitis, in which it is used, it averts the immediate danger to life, and affords time and It can effect no more: it can do no less. In whatever malady laryngismus occurs, whether it assume opportunity for remedies. In epilepsy, in which it never the paralytic form, as in inorganic apoplexy, or the spasmodic, before was used, it does more; it averts the immediate and the remote dangers to life and intellect and limb; it renders as in inorganic epilepsy, this is the office of tracheotomy; the attack abortive, reducing it from the graver to a milder the effects of this laryngismus are, and must be, obviated. It is not therefore for apoplexy, or epilepsy, or tetanus, or form, affording time and opportunity for remedies, and for the -any other disease, that tracheotomy can be recommended; but gradual subsidence of augmented excitability of the spinal whenever such disease assumes the laryngeal form, laryngismus centre, and of the susceptibility to attacks, excited and left by being superadded to the other symptoms, and becoming the the disease in its unmitigated form. especial source of danger, then tracheotomy averts this .
danger!
The disease is thus made to assume a modified, or, it may be called the abortive, form. Its character is mitigated; its tendency, whether this be to apoplexy, to mania, to asphyxia, is prevented. Apoplexy and epilepsy cease to be the apoplexia and the epilepsia laryngea. Life and intellect may be preserved. Let the reader look over the arrangement in THE LANCET of Nov. 13, 1852, and he will perceive that this is, not in - epilepsy only, but in every case, the object, the effect of tracheotomy. In laryngitis, tracheotomy averts the impending danger to life, and gives the opportunity for the use of remedies for removing the original disease. In the case of a foreign body in the trachea, tracheotomy may lead to its extraction by the orifice. But this is an exception to the rule, and tracheotomy is no more to be expected to cure apoplexy or epilepsy than to cure laryngitis. Its influence is to modify and mitigate their severest form, converting the apoplexia laryngea and epilepsia laryngea into the apoplexia trachelea and epilepsia trachelea, which may indeed still be severe, but which generally assume a mild and fading form, with far less dire effects and consequences, immediate and remote. And again, space is offered for the use of remedies. The same motive which urges to the institution of tracheotomy in laryngitis, must urge us to its institution in the apoplexia laryngea, and the epilepsia laryngea, &c. ; and the same * Starkie
on
Ev.
In
one
trachea;
case, that of Mr. Cane, the tube is still worn in the seizure of any kind has occurred during twenty-
no
three months, although they had formerly occurred in their worst form, on an average, every third day. In a second, that of Mr. Mackarsie, there has recently been the threatening of a return of paralysis, experienced once, unknown to me, formerly. It is to be feared, therefore, that there may be organic disease. Still the operation has effected all that it can effect in any case; it has, as it ever must do, averted the effects 3 of laryngismus, and changed the form of the disease from the laryngeal to the tracheleal. In the third case, or that of Mr. Anderson, the same good effect was produced; but the patient has died with fatty degeneration of the heart. It will be remembered that the poor woman’s father was epileptic; that she had been afflicted during twenty-four years out of thirty-six, which was her age. She was of the frailest form, pale and thin, and of leaden aspect; she had minor attacks after the graver had been obviated, and she either died from epilepsia syncopalis, or from syncope arising from the affection of the heart. On a post-mortem examination, it was found that though the tracheal tube had been worn during many months, no inflammation had extended along the internal membrane of the trachea. ____
I will now beg my reader again to revert to the classification cases in which tracheotomy may be required, given in THE
! of