Homicidal Insanity, 1800-1985

3. The Development of a Medical Jurisprudence of Insanity

The Development of a Medical Jurisprudence of Insanity 3 Concurrent with the growth of psychiatry as a medical specialty in the mid-nineteenth century, medico-legal experts began to address the issue of insane homicide within the context of involuntary commitment, criminal proceedings, and release from the asylum. At no time during this early asylum period did physicians believe that all mentally ill people were dangerous. The readiness to commit persons diagnosed as insane was not based upon the prediction of dangerousness, but upon the belief that they were in need of protection and refuge. Between 1840 and 1869, the asylum approach to psychiatry was established and came to a brief fruition; then flaws became apparent . This approach disappointed proponents because it was founded upon the assumption that the insane could be cured by their prompt dispatch to the controlled environment of the asylum . It is true that they often improved substantially with classic moral management. But the founders of the specialty did not have the opportunity to test the hypothesis or to improve the method. Early in the asylum period, the ideal of a controlled environment became more and more difficult to achieve. Buildings crumbled, destructive lunatics destroyed the decor, and single rooms became dormitories as the need for room outstripped the capacity of the 38 Medical Jurisprudence 39 institution to maintain the tasteful environment that was essential for providing the moral treatment. I But, even after medical superintendents accepted the reality that insanity was not cured merely by the asylum environment, these institutions continued to be built, expanded, and funded because they met social needs, not the least of which was to isolate the insane, whom people believed could be dangerous. Between 186o and 1870, the practice of psychiatry was plagued not only by internal theoretical disagreemellts, but also by challenges from outside the profession to the authority of the asylum superintendent to commit and detain people. After 1870 the new medical specialty of neurology challenged the basic tenets of the asylum superintendents . 2 The superintendents unhesitatingly identified the homicidal insane in their own institutions and exercised their prerogative to control them with mechanical restraints. But the authors of the annual reports of the early asylums devoted more attention to the number of suicidal patients in need of the watchful attention of the attendants than to the presence ofhomicidal lunatics. Although some of the patients were certainly dangerous, to have called attention to their presence would have militated against the therapeutic image of the asylum. 3 Later in the century, when asylums became grossly overcrowded, the presence ofthe homicidal insane would give rise to discussion and rhetoric about the "virtuous" and the "wicked" insane, along with a cry for separate establishments . The belief that the homicidal insane were essentially depraved and therefore deserving ofsome punishment still informed psychiatric thinking in some instances. The Alienist as Medico-Legal Expert By 1840 physicians, and the public as well, associated insane homicide with distinct mental phenomena. In the spirit ofthe Enlightenment , more and more the medical superintendents were called upon by the courts to make discriminatoryjudgments about whether a murderer was a homicidal lunatic or merely a criminal. 40 Homicidal Insanity, 1800-1985 Some superintendents, and later neurologists, particularly those who were guided by a religious devotion to the primacy ofreason, ignored the empirical data and applied their own standards to the diagnostic process. Differences of theoretical opinion surfaced in medico-legal cases in which alienists publicly disagreed. 4 Experts in the jurisprudence of insanity generally agreed about the concepts of partial insanity (homicidal monomania, homicidal impulse, moral insanity) postulated by Esquirol and Prichard , though speculation prevailed about whether or not the intellect could remain intact in any insanity. When Forbes Winslow , the British alienist, wrote The Plea ofInsanity in Criminal Cases (1843), he recognized the existence of partial insanity and monomania (that is, delusions without other signs, such as disorientation and hallucinations), but he did not equate the two mental conditions. He was also adamant in his rejection of the existence of delusion as a test for insanity; in fact, he believed that no single test was available and that the lunatic's mental state could be assessed only within the context of its own history. Winslow disagreed with Prichard that the dangerous lunatic acts without motive: "Are not the insane often impelled to the commission of acts ofviolence and murder by the same motives, feelings, andpassions, that...