COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00030066 mm Columl3ia ©nibergitp, ^ in tJje Citp of ^eto i^orfe ""^^ COLLEGE OF PHYSICIANS ^ AND SURGEONS Reference Library Given by Crh-^^ '-<^*-<-<- A SYSTEM OF LEGAL MEDICINE. VOLUME II. A SYSTEM OF LEGAL MEDICINE BY ALLAN McLANE HAMILTON, M. D. CONSULTING PHYSICIAN TO THE INSANE ASYLUMS OF NEW-YORK CITY, ETC., ETC. AND LAWRENCE GODKIN, ESQ- OF THE NEW-YORK BAR WITH THE COLLABORATION OF PROF. J AM ES F. BABCOCK, LEWIS BALCH . M . D. , JUDGE S. E. BALDWIN, LOUIS E. BINSSE, ESQ.., C. F. BISHOP, ESQ.., A. T. BRISTOW, M. D., B. F. CARDOZO, ESQ.-, C. G. CHADDOCK. M. D., A. F. CURRIER, M. D., C. L. DANA, M. D., GEO. RYERSON FOWLER. M. D., W.T.GIBB, M. D., W. S. HAINES, M. D., F. A. HARRIS. M. D., W. B. HORNBLOWER,ESQ..CHAS.JEWETT, M. D., P.C. KNAPP, M. D., R. C. McMURTRIE, ESQ.., C. K. MILLS, M. D., J. E. PARSONS, ESQ.., C. E. PELLEW, E. M., JUDGE C. E. PRATT. W. A. PURRINGTON, ESQ.-, B. SACHS, M. D., F. R. STURGIS, M. D., BRANDRETH SYMONDS, M. D., V. C. VAUGHAN, M. D. ILLUSTRATED VOLUME II NEW-YORK E. B. TREAT, 5 COOPER UNION 1894 { Copyright, by E. B. Treat, New York. 1894. All rights reserved. LIST OF COI^TEIBUTOES. VOLUME II. SIMEON E. BALDWIN, LL.D., one of the Judges of tlie Supreme Coiu't of the State of Connecticut ; Professor in the Law Department of Yale Colleg-e. LOUIS E. BINSSE, of the New York Bar. CHARLES GILBERT CHADDOCK, M.D., Professor of Diseases of the Nervous System, Marion-Sims College of Medicine, St. Louis, Mo. ; Nem'ologist to Rebekah Hospital ; formerly Assistant Medical Super- intendent of the North Michigan Asylum. ANDREW F. CURRIER, M.D., Gynecologist to Outdoor Department, Bellevue Hospital. CHARLES L. DANA, A.M., M.D., Professor of Nervous and Mental Dis- eases in the New York Post-Graduate Medical School and in Dart- mouth Medical CoUege; Visiting Physician to BeUevue Hospital; Neurologist to the Montefiore Home and to the Out-Patient Depart- ment, BeUevue Hospital ; Ex-President of the American Neurological Association and of the New York Neurological Society; and Presi- dent of the Practitioners' Society of New York City. GEORGE RYERSON FOWLER, M.D., of Brooklyn, N. Y., Surgeon to the Methodist Episcopal Hospital ; to St. Mary's Hospital ; Considt- ing Surgeon to the Relief Hospital and to the Nor^v^egian Hospital ; Examiner in Siu-gerv, State Board of Medical Examiners. LAWRENCE QODKIN, of the New York Bar. 5 6 LIST OF C02iTBIBVT0RS. ALLAN McLANE HAMILTON, M.D., Consulting Physician to the In- sane Asyhims of New York City ; Consulting Neurologist to the Hos- pital for Ruptured and Crippled and to the Hospital for Nervous Diseases. WM. B. HORNBLOWER, of the New York Bar. CHARLES JEWETT, A.M., M.D., SC.D., Professor of Obstetrics and Pediatrics in the Long Island College Hospital; President of the New York Obstetrical Society and President of the G-ynecological Society ; Corresponding Member of the British Gynecological Society. PHILIP COOMBS KNAPP, A.M., M.D., Instructor in Nervous Diseases at Harvard Medical School. CHARLES K. MILLS, A.M., M.D., Professor of Mental Diseases and of Medical Jurisprudence in the University of Pennsylvania ; Profess- or of Diseases of the Mind and Nervous System in the Philadelphia Polyclinic; etc. JOHN E. PARSONS, of the New York Bar. CALVIN S. PRATT, one of the Justices of the Supreme Court of the State of New York, and Lecturer upon Medical Jurisprudence at the Long Island Hospital College. B. SACHS, A.M., M.D., Professor of Mental and Nervous Diseases in the New York Polyclinic ; Consulting Neurologist to the Italian Home and to the Montefiore Home for Chronic Invalids. GEORGE De FOREST SMITH, M.D., of New York. FREDERICK R. STURGIS, M.D., one of the Visiting Surgeons to the City Hospital, Blackwell's Island. CONTENTS OF VOLUME II. PAGE Duties and Responsibilities of Medical Experts 13 wm. b. hoknblowek. Insanity in its Medico-Legal Bearings 19 ALLAN McLANE HAMILTON, M.D. Mental Responsibility of the Insane in Civil Cases 169 CALVIN S. PEATT. Insanity and Crdie 175 B. SACHS, a.m., M.D. On the Relations of Mentai. Defect and Disease to Crdiinal Responsibility 217 louis e. binsse. Aphasli and other Affections of Speech 259 charles k. mills, m.d. The TRAU5L4.TIC Neuroses : being a Description of the Chronic Nervous Disorders that follow Shock and Injury 297 CHARLES L. DANA, A.M., M.D. The Effects op Electric Currents of High Power upon the HiBL^N Body 363 ALLAN McLANE HAMILTON, M.D., and GEORGE De FOREST SMITH, M.D. Accident Cases „ 377 lawrence godkin. Mental Distress as an Element of Da:\l\ge in Cases to Re- cover FOR Personal Injuries 385 JOHN E. PARSONS. 7 8 CONTEXTS OF VOLUME II. PAGE Feigned Diseases op the Mind and Nervous System 391 PHILIP COOMBS KNAPP, A.M., M.D. Birth, Sex, Pregnancy, and DELI^^:RY 417 ANDREW F. CURRIER, M.D. Abortion and Infanticide 4G7 CHARLES JEWETT, A.M., M.D., Sc.D. Oenito-Urinary and Venereal Affections in their Medico- Legal Relations 497 F. R. STURGIS, M.D. Marriage and Divorce 517 SIMEON E. BALDWIN, LL.D. Sexual Crbies 525 charles gilbert chaddock, m.d. s^ i- Surgical Malpractice 573 george ryerson fowler, m.d. Appendix 631 Index 681 LIST OF ILLUSTEATIO^^S. VOLUME 11. PLATES. PAGE I. Microscopic Appearance of Brain of Epileptic, showing Celln- lar Degeneration 71 II. Criminals who have become Insane. Degenerate Type 183 III. Criminals by Reason of Insanity 187 lY. Hysterical Hemiplegia, showing the Peculiar Dragging of the Foot 337 Y. Male Hysteria, showing Characteristic Physiognomy 345 YI. Lnngs and Intrathoracic Organs of New-born Child, a A^ictim of Infanticide '473 WOOD-CUTS AND HALF-TONE ENGRAYINGS. Fig. 1. Sknll of Tamping-iron Case 21 Figs. 2-4. Diagrams iUnstrating the Ramifications of Fibers and the Location of the Basal Sensory Area of the Brnin 22 Fig. 5. Diagram representing the Conrse of the Pyramidal Fibers. . 23 Fig. C. Diagram representing the Topography of the Cortical Ai-eas of the Left Hemisphere 24 Figs. 7-10. Sections of the Cerebrnm sliowino- tlie Association Fiber Systeni 25 Fig. 11. Arterial Snpply at the Base of the Brain 2G 9 10 LIST OF ILLUSTRATIOXS. PAGE Fig. 12. Male Sexual Pei-vert 50 Fig. 13. Braiu of Mierocephale G7 Fig. 14. Physioguomy of Chronic Excited lusaue Patieut To Fig. 15. Physioguomy of Chronic Depressed Insane Patient 74 Fig. 16. Writing of a Paranoiac 75 Fig. 17. "Writing of an Educated Paretic Dement 7(3 Fig. 18. Writing showing Deterioration in Paretic Dementia 77 Fig. 19. OthaBmatoma, or •■ Insane Ear " 7$ Fig. 20. Casts of Vault of Month, showing Defects in Hard Palate. . 82 Fig. 21. Casts of Palates. sh<)wing Standard Types and Changes found in Adolescent Insanity 83 Fig. 22. Fantastic Decoration in Pai"auoia 87 Fig. 23. Physiognomy of Melancholia 99 Fig. 24. Physiognomy of Mania 101 Fig. 25. Kavachol 184 Fig. 26. Head Configuration of Forger , 185 Fig. 27. Head Configuration of Bandit 185 Figs. 28-33. Types of Instinctive Criminals 186 Figs. 34—36. Diagi-ams showing Ai-ea over which Cutaneous Irrita- tion produces Cremasteric Keflex Conti'action and Knee- jerk 314 Figs. 37, 38. Ataxiagi-ams 315- FiGS. 39. 40. Visual-field Limitations 317, 318 Figs. 41, 42. Comparative Size and Kelations of Brain and Spinal Cord 32a Fig. 43. Points of Exit of Cutaneous Branches of Spinal Nerves. . . 324 Fig. 44. Topography of Back, .showing Relation of Points of Origin and Exit of Spinal Nerves to the Spinous Processes 325 Figs. 45-52. Diagrams showing Distribution of the Sensoiy Nerves, 327, 328 LIST OF ILLUSTRATIONS. \\ r.\<.i: Fig. 58. Diagrams showing Different Modes of Hysterical Antes- tlicsia 'M(\ Figs. 54-5G. Aiiiestliesia witii Hysteria, and Lesions of the C'anda E({uiiia 34 1 Fig. 57. An;i3sthesia in a Case of Myelitis 3-12 Fig. 58. Diagram sliowing Normal Field of Vision of Right Eye for Color and Form 343 Fig. 59. Same for Left Eye 343 Figs. G0-G2. Examples of Hermaphrodism 420-422 Fig. G3. Diagram showing Relation of Parts in Hermaphrodism . . . 423 Fig. G4. Cnrrier's Case of Enlarged Labia Minora 424 Fig. G5. Figure representing Female Organs of Generation 42.5 Fig. GG. Currier's Case of Double Uterus 446 Fig. G7. Currier's Case of Tubal Pregnancy 448 Fig. G8. Diagram illustrating the Enlargement of the Uterus in Pregnancy 454 Fig. 69. Showing Annular Hymen 529 Figs. 70, 71. Showing Crescentic Hymens 530 Fig. 72. Showing Hymen Fimbriatus, Intact 530 Fig. 73. Showing Ruptured Hymen Fimbriatus 530 Fig. 74. Showing Hymen Sa?ptus, with Unequal Openings 531 Fig, 75. Showing Hymen with Posterior Rudimentary Septum. . . . 531 Fig. 76. Showing Ruptured Crescentic Hymen, Avitli Two Lateral Lacerations ... 532 Fig. 77. Showing Circular Hymen, Torn in Several Places 532 Fig. 78. Showing Ruptured Hymen Saeptus 533 DUTIES AND RESPONSIBILITIES OF MEDICAL EX- PERTS. BY WM. B. HORNBLOWER. One of the most important and striking de^'^elopments of modern ju- risprudence is in the line of expert testimon3^ The common law recog- nizes the right of parties to call as witnesses those who are specially skilled in or familiar with any particular art or science, in order to ex- plain the meaning of words or phrases having a pecuhar meaning in such art or science. From this has developed the practice of caUing ex- perts in mechanics to give opinions in patent cases, and experts in medical science to give opinions in cases involving medical questions. The most important class of cases in which medical experts are called to give testimony is that involving the issue of sanity or insanity. Many embarrassing difficulties have arisen in cases of this kind as to the examination of expert witnesses, and many well-founded objections have been made to the methods employed in such examination in the courts in this country and in England. Some of the most sahent ob- jections are to the employing of persons as paid medical counsel by one side or the other ; the examination of the exj)erts by hypothetical questions framed in the interest of one side or the other ; and the laying down of tests of sanit}'^ or insanity by the courts as matters of law, in- stead of treating the questions as pui'ely medical ones to be decided by the weight of the expert testimony. Before considering any of these objections it is proper to state in a summary manner what is the general practice prevailing in the courts of England and of this country. To cite authorities in illustration of the practice, or to endea\'or to differentiate the practice of the various juris- dictions, or to state the limitations and exceptions to the rules laid clo^vn, would involve a treatise. My function is simply to give results and to state the practice in general as it now exists. In the first place, it is a principle of our jurisprudence that the ques- tion of sanity or insanity, when it arises as an issue in the case, is to be determined by the court, or, if it be a jury case, by the jury, and is not to be decided by the medical experts. Again, the question of sanity or insanity presents itself in different shape in different forms of litigation, and the legal rules as to what constitutes sanity or insanity in the case before the court are laid down by the court f(n* the guidance of the ex- perts as well as the guidance of the court itseK or the jmy. 13 14 A SYSTEM OF LEGAL MEDICIXE. Thus, iu criminal trials where the accused is defended on the ground of insanity, the courts have laid do-wu certain rules of law as to what degree of mental or moral obhquity is sufficient to shield a man from punishment and to make him, in a legal sense, irresponsible. The com-ts have differed mdely as to these tests, and no rule of law with reference thereto is universally accepted even now; but nevertheless the eoiu-ts assume the right to instruct the jiuy as to what does constitute sufficient insanit}' to be a defense. One of the tests laid do^^m by some of the courts has been that defend- ant must have been so far uncler the influence of insane delusion at the moment of committing the act as not to be conscious of right or wi-ong. This test has the sanction of the House of Lords. Another test laid down is that the defendant is responsible for his act if he had sufficient intelligence to know tlie physical consecpiences of the act, and that it was a Avrongful act and in violation of the law, whether he was under the influence of moral delusion or not. But whatever test be adopted, it is well settled in practice that the court is to declare the rule and the jmy are bound to accept it. Again, in the trial of mil cases, the tests of competency to make a will are laid down by the coiu-ts. The most usual rule laid down is that the testator was competent to make a will if he had sufficient intelligence to remember and understand the nature of his property-, the objects of his bounty, and those having claims upon him, even tliough he may have been to some extent mentally unsound. Yer}^ severe criticism has been indulged in by some, medical men and alienists upon this practice of laying down the test of criminal responsibility and testamentary capacity by the courts. It has been urged that the ques- tion of insanity is one purely of medical science, and that the tests of in- sanity should be derived from the testimony of the experts, and not from the opinions of the judges. Tliis objection assumes that the issue is purely one of sanity or insanity. There are, howevei', various degrees and phases of mental unsoimduess. A man may be to some extent men- tally unsound, and yet he may not be in such a condition of mind that as between him and the community he should be shielded from the conse- quences of criminal conduct. So, too, a man may have mental delusions or weaknesses, and yet not be incapable of disposing of his property. It would seem, therefore, proper that there should be some general i-uk'S of law laid down for the various classes of cases where insanity is an issue, and that there should be some guide laid down for the instruction of juries and judges in the different classes of cases. At any rate, such is the practice. The rule is thus stated by an eminent authority ("N'^niarton and Stille's Medical Jimsprudence, sec. 193) : ''AVliile experts maybe called to testify as to states of mind and conditions of health, it is for the court to de- clare whether such states and conditions constitute irresponsibility." Another well-settled rule is that medical-expert ^^^tuesses may be permitted to state, in connection with their opinion, as to the sanity or insanity of a person, based upon the testimony in the case, the reason upon which it was founded; but inferences from the facts as to guilt or innocence of crime cannot be testified to. Nor can the witnesses be al- lowed to testify that certain facts indicate consciousness, apprehension, truthf Illness, etc. (See People vs. Barlrr, 115 X. Y. 475.) DUTIES AND BESPOXSflULITIES OF MEDICAL EXI'EIITS. 15 Again, anotliei' rule observed in tlie courts on the examination of ex- perts is that their ()])inion is to be asked, not upon the ease as a wliole, but upon hypothetical (piestions presented to theni. And it is further the practice to allow each side to call and to pay expert witnesses, and to obtain their opinions upon the hypothetical (juestions framed ])y the respective counsel. The theory on which the experts are examined is that they are testifying to the rules of a particular science as applied to a given state of facts. Those rules are themselves facts, just as much as are the other facts testified to by witnesses from their senses of sight and hearing. Thus the laws of chemistry may be testified to by a chenucal expert — the chemical effects of certain acids, and the results of chemical analyses, for these are as nnich facts as is the label on a cei-tain bottle, or the name of the apothecary from whom the bottle and its contents were purchased. The primary object, therefore, of expert testimony is, not to prove opinions, but facts in the shape of rides of science or art generally recognized by those who are especially instructed in such sci- ence or art. In certain domains, however, of science and art it is possible for men of equal attainments to difi'er in their -views as to the rules ap- plicable to a given state of physical or mental phenomena presented to them ; hence comes the sphere of what is called " opinion evidence." The object to be attained by the courts is to limit the opinion as much as possible, and to get as nearl}^ as possible at the rules generally recognized by the profession of which the expert is a member, and thereby to keep the issue within the realm of facts. This is the theory on which hypothetical questions are based. When an expert witness has a hypothetical question put to him and is asked to give his opinion upon the state of facts presented, he is in legal theory asked to state what he understands to be the fact with regard to the medical rules applicable to that set of circumstances. In criminal cases, or cases de lunatico inqu'wendo, it is, of course, feasi- ble for the expert witnesses to personally examine and obsei've the party, and they can thus form an opinion as to his mental condition at the time of such examination, which they can express in the shape of a conclusion, exijlaining the grounds on wliich the conclusion is based. In will con- tests, however, which form a very large class of the controversies in^-olv- ing the issue of mental competency, this is impossil)le. In such cases the hypothetical question is the only recognized mode of eliciting the tes- timony of expert witnesses — i.e., a question putting a supposed case based upon the facts as claimed to be established by the other witnesses, and inquiring whether if such and such were the facts as to the conduct, character, and history of the deceased he would be in the judgment of the witness of sound and disposing mind and memory. Many forcible ol^jections are urged against the use of the In'jiothetical cpTestion. It is claimed, and with too much truth, that this form of ques- tion assumes as proved whatever the counsel putting the question has endeavored to prove, and combines insignificant witli inq»ortant circum- stances, and alleged facts, supported by slight and pci-haps worthless testimony, with other facts of which the proof is strong and convinc- ing, while omitting still other facts of equal or of greater importance which may l)e overwhelmiugiy established upon the other side ; that this form of question is in eifect nothing more nor less than a summing up by counsel, assuming all the allegations of fact in his favor of which IQ A SYSTEM OF LEGAL MEDICLNE. tliere may be only a sciutilla of proof, aud omitting all other facts, how- ever eleai'ly established. Expert testimony based iij)on such one-sided hy|Dothetical questions is almost of necessity favorable to the questioner, and the seeming inconsistency of expert "svitnesses of equal ability and learning is veiy largely due to this mode of examination. In other words, expert witnesses who might agi'ee if the same hj^jothetical ques- tion were put to them almost of necessity disagree when dii-ectly op- posite h;\i3othetical questions are put to them. Various remedies for this evil have been suggested, such as haAdng the hypothetical questions fi*amed by the court, based on the testimony of each side, and asking the witness to give his opinion on each theoiy. This practice, however, would only partially obviate the difficulty, unless the court should, in framing the question, assume to decide what facts had been estabhslied on either side. In will cases there seems to be no escape fi'om the necessity of hypo- thetical questions in some form so long as the issue of sanity or insanity is to be decided by the coiu-t or the jury. It manifestly is impracticable to ask the expert witness to give his opinion on the whole case as to whether the deceased was sane or insane, for this requires the expert to decide the whole case,, and notliing remains for the court or the jury to do except, perhaps, to decide between conflicting exjDert e^ddence ; and this, of coui'se, is inconsistent with oiu- whole theory of trial by coui"t or jury. It might, jDerhaps, be feasible to have the court or the jiuy make find- ings of fact as to the evidence of conduct, character, and history, and then have a commission of experts decide whether, on such findings, the deceased was or was not insane. This, however, is also open to manifest objections, since it would involve, in order to be of any value to the ex- perts, a multitude of findings invohdng minutife of conduct which would be almost hopelessly bewildering to a jury, aud in a long trial, intoler- ably biu'densome to the coui't. The true remedy for the evils that undoubtedly exist in the trial of cases invohijig the question of insanity is to have this question sepa- rately passed upon, as far as practicalile, b}^ a commission of experts. Legislation in the State of New York has set an example in this direc- tion. By section 658 of the Code of Crimiual Procedure of the State of New York, it is pro\dded that when a defendant pleads insanity the court may appoint a commission to examine him and report to the com't as to his sanity at the time of the commission of the crime. It is fiu-ther pro- vided that if a defendant in confinement under indictment appears to be at any time before or after conviction insane, the court may, unless the defendant is under sentence of death (in which case powers are conferred by other statutes upon the governor to examine into the cpiestion), ap- point a like commission to examine him and report to the court as to his sanity at the time of the examination. Aud i£" the commission find the defendant insane, the trial or judgment must be suspended until he be- comes sane ; and the court, if it deem his discharge dangerous to the public peace or safety, must order that he be committed in the mean- time by the sheriff to a State lunatic asylum, aud that upon his becoming sane he be redelivered hy the superintendent of the asylum to the sheriff, whereupon he must l;)e brought to trial, judgment, or execution, as the case may be, or be legally discharged. (Code of Criminal Procedure, sees. 659, 661.) DUTIES AND IlJ'SlIiILrril<:S OF MEDICAL EXPERTS. ]7 These i)rovisions of tlie Code of Criminal Procedure, eiiaet(;d in 1881, supersede and (nilart>e the previous provisions of the Laws of 1874, (-hap- ter 44(5. That aet, for some reason the propri(;ty of wliich it is diflh'ult to understand, restrieted its provisions to the erinies of "arson or mur- der, or attempt at murder, or highway robbery," while the present act •extends to all crimes. There are constitutional difficulties in the way of inaking the findings of the commission conclusive against the accused in criminal cases if they find him sane at tlie time of the alleged offense, since that would. deprive him of his riglit to a trial by .jury on that issue, which is an essential part of the inquiry as to his guilt. It would be well, however, if in all civil cases in which the issue of sanity arises that qnestion could be submitted to a commission of experts. In equity and probate cases there is no constitutional right to a trial by jury in most jurisdictions, and in such cases this mode of disposing of this issue would seem to be feasible and expedient, and would obviate many of the objections now existing in the trial of cases where expert evidence as to sanity is called for. There are certain cases in which expert evidence is frequently given where it would seem to be wholly inappropriate. Thus in murder cases the accused is very often defended on the groniid of momentaiy or tem- porary insanity. This defense really amounts to little more than excus- able and nncontrollable anger. It is usually availed of in extreme cases, such as where the accused has killed the seducer of his wife. In such cases the jury, prompted by the feeling that the accused was justified in the killing by reason of the injury received from the deceased, readUy avail themselves of the excuse offered by the defense of temj^orary insan- ity. Yet it is manifestly absurd, in such a case, to call medical experts to prove or disprove the proposition that a man who is perfectly sane the moment before the act and perfectly sane the moment after can be temporarily bereft of reason by rage and indignation so as to be irre- sponsible for his acts. This is in no proper sense a medical or scientific question, but a question of common sense and common experience which a judge or a jury are competent to decide for themselves. Much criticism has been indulged in by the courts as to the vjilue of -expert evidence. Thus Lord Campbell's remark in the case of the Tracy Peerage, 10 CI. & Fin. 191, has been often c[uoted to the effect that '' skilled witnesses come witii such a bias on their minds to support the •cause in which they are embarked that hardly any weight should be given to their evidence." This criticism is unduly severe. There can be no doubt that the function of expert witnesses is a most valuable one, and is in fact indispensable to the proper administration of justice in the courts. There is much to be said in favoi- of having certain persons selected l)y tlie Suj^reme Court of the State from the medical men attached to the State insane asylums and other institutions, and from among those spe- cially skilled in questions of mental disease, to act as experts whenever desired by parties in the trial of causes^such experts to be paid a cer- tain sum 2)er diem to be fixed by law. The experts so selected by the court would feel a degree of responsibility to the court, and a degree of freedom from obligation to the party (tailing them, w^hich would tend to 7nake them independent and impartial. 18 A SYSTEM OF LEGAL MEDICINE. It is needless to urge the duty of medical experts to free tbemselves- as far as possible fro;:u the bias of theii' retainer. It should he the aim and pride of the medical expert to realize that he is after all not a counsel, but a witness called upon to testify to facts of medical science with which he is supposed to be familiar, and that those facts should be testified to fully, frankly, and faii-ly, just as much as if he were called as a witness to prove what took place at the time of an alleged murder. It is, of course, natural that pride of opinion should be evoked, and that bias should be aroused, on the part of the medical expert, especially when sub- jected to harassing and sometimes aunojdng and disrespectful cross-ex- amination. The obligation, however, to tell the truth, the whole truth,, and nothing but the truth, should be constantly before the mind of the medical expert. It is not his function to carry on a dialectical warfare- with opposing counsel or opposing experts, but to give a fuU and com- plete statement of' the medical rules apiDhcable to the case in hand, on the hj-pothetical questions put to Mm, without fear or favor. INSANITY IN ITS MEDICO-LEGAL BEARINOS. BY allan mrlaxe hamilton, m.d. Part L — General Introduction. Mind is that niaiiifestatiou of life which depends upon the functional activity of the brain, and is expressed in the exercise of feeling, thought, and volition. In the light of modern psychological research I do not believe it can be regarded as a distinct entity, as it has been for so long a time, and is to-day, by some metaphysicians and many theologians. It is my purpose to Ijriefly consider normal and diseased function alone, referring my i-eaders to the accumulated researches of a host of psychi- atrists, physiologists, and anatomists for extended data. The human being possesses an ego which is the basis of all mental activity, and through it he realizes the relations he l)ears to the external world, as well as the value of impressions which have been transformed into concepts, while previous experiences are stored up and form the basis of thought and action. The outer world Ijears an indirect relation toward him through external experience. All of his ability for weighing, coordinating, and using his own internal formidated impressions (con- cepts), as well as of putting himself in every way in proper touch with outside things, depends upon the faculty of attention (apperception). The power of attention and its connection with concept selection deter- mines greatly the intricacy and degree of tliouglit and action. The many steps of mental development have 1)een ti-aced h\ pains- taking ol)servers whose results are incontrovei'til^le, and in tliese days of progress we are furnished witli indisputable facts wliich show bow the mind may be partially or generally destroyed in a distinctly definite man- ner by morbid processes and focal disease. Extirpation of certain tracts or regions is followed by perversion or abolition, it being possibh* to repeat such experiments over and over again if one chooses. We have l)een shown that ancephalous monsters exist, and modern localization has thoroughly changed our inexact and speculative knowledge of lu-ain function, Avhich a quarter of a century ago ])artook largely of the nature of guess-work. It is, moreover, possil)le, after studying the questions of heredity and environment, to realize the influences that materially act in the genesis of mental development or decay. The healthy play of hu- man passions and feelings depends upon cerebral integiity, and possibly before long our knowledge and appreciation of the origin of many of the in 20 A SYSTEM OF LEGAL MEDICINE. higher attributes of mental f imctiou -v^ill have a material and satisfaetoiy explanation. For the proper study of the mind in health and disease we must \dew the subject fii-st from the side of deA^elopment and degenera- tion, and, again, we must consider the coordination and mutual depend- ence of cellular functional activity and efferent and aiferent perfectness of communication. It is better to break away from the ii-on-clad so-called divisions of mind adopted by the older metaphysicians and to consider the manifestations of brain action as not only extremely variable but com- plex in their display. After all, the power and extent of mental action depend upon the capacity of the apparatus which gives bii'th to psychic activity. With the more primitive nervous organs we have nothing here to do, but the study of the mind of man is before us, and we shall proceed to the discussion of its impairment. It may be assumed beyond doubt that the growth of mteJIigence tears relation to the complexHij of the nervous organization or the evolu- tion of the higher ganglia. It would be difficult to form any exact esti- mate of its extent, and the j)oint to which it may be developed even in the lower animals, but it may be assumed that convolutionary perfection, completeness in the connection of cells and groups of cells, determines the possibilities of mental growth. There is no absolute indication of intellectual power to be derived fi'om the size of the brain or the shape of the head alone, except in a most general way. Students of craniology have called attention to the asymmetry of the cranium and the irregu- larity and exaggeration of the fissiu-es which divide the cerebral convo- lutions, but anything more than this is mere guess-work. Abundant statistics are on record to i3rove that the heaviest brains do not go with \h.Q grandest intellects, but, on tlie contrary, these statistics indubitably show that some of the gi'eatest minds are the product of insignificant brains so far as mere weight is concerned. We are safe, however, in fixing the minimum weight of the normal brain, and assuming that cer- tain figures must be associated with a very low degree of intelligence, or none at aU. Gratiolet {The Brain as an Organ of Mind, Bastian, p. 36) has fixed the lowest limit compatible ^^dth. ordinary intelligence at 900 drams ; Broca at 907 for the female and 1049 for the male. The aver- age weight of the human brain has been estimated by Shaipey as fol- lows : maximum weight of adult male brain, 65 oz. ; average weight of adult male brain, 49J oz. ; minimum weight of adult male brain, 34 oz. ; maximum weight of adult female brain, 56 oz. ; average weight of adult female brain, 44 oz. ; minhnum weight of adult female brain, 31 oz. Mor- ris has re])()rted the hea^'iest brain so far recorded, the weight being 67 oz. [Brit. Med. Jour., October 6, 1872). After all, the true test of intelli- gence is that of general structui-al development, and it is i;»robable that, if the microscope could be brought to reveal the most delicate commissural connections, tlie brain nearest perfection would show a well-d(n-eloped convolutionary surface, jjlentifnlly supplied with corti- cal cells, and with intricate communications between separate groups. The brains of persons of low intelligence — idiots and others — on the con- trary, slu)w a flatness of the external surface, Avith imperfectly defined and se])arated convolutions, a notable degree of flatness of these, as well as asymmetry or a distinct difference between the two hemispheres. At another part of this article these matters will be considered in extenso. The lessons of physiology and pathology throw much light upon the JXSJXlTY JX ITS MEDICO-LEGAL BEARINGS. 21 functions of the brain and changes in the genesis of mental expression that follow its partial removal or impairment by disease. An experiment often performed iu the pli^'siologieal lal)oratory consists in the removal of the cerebrum from pigeons and frogs, resulting in the deprivation of all mental control and the persistence onl}'^ of reflex function , pediculo-frontal section ; c, c, frontal section; d, d, parietal section; e, c, pedicnlo-parietal ; /, /, occipital section. The uioZet tinting indicates the psychic zone; bhtc, the ,sf /(.■^ory ; red, the motor; green, the geniculate centers (of face, and nerves con- cerned in mastication as well as the hypoglossal) ; yellow, the center of apliasia. I, Agraphia center; J7, aphasic center; JIJ, center of lovi^er extremity ; Jl^ of superior extremity; F, motor center of face ; VI, center of word-blindness ; VII, center of liemianopsia ; VIII, center of word-deafness. Besides these there is a center in the unciate gyrus, which probably controls the sense of smell. INSAXITl' IX I'L'i MEDICO-LEGAL BEARINGS. 25 Fig. 8. --h Fig-. 9. Fig. 10. Sections of the cerebrum showing the association fiber system. (Testut.) Figs. 7 and 8.— Pediciilo-f rental section : 1, 2, 3, first, second, and third frontal convolutions; 4, island of Reil; 5, orbital convolutions; 6, anterior extremity of temporal convolutions; 7, convolutions of corpus callosum; 8. superior pediculo-frontal fibers; i'. middle pediculo- frontal fibers; 10, inferior pediculo-frontal fibers; 11, orbital fibers; VZ. corpus callosum: 13, cau- date nucleus; 14, internal capsule; 15, lenticular nucleus; 7, agraphic center; 77, aphasic center (see Mill's article); A, A, psychic fibers (violet); 7?, aphasic fibers (yellow); C, sensory fibers (blue). Figs. 9 and 10.— Frontal section of cerebrum: 1, ascending frontal convolution; 2, foot of ascending parietal convolution; ;i, island of Reil: 4, 4', 4", first, second, and third temporal convolutions; .5, superior frontal fibers: (i, middle frontal fibers; 7, inferior frontal fibers; 8, sphenoidal fibers: 9, cm-pus callosum; 10, caudate nucleus; 11, optic thalamus; 12, internal capsule: 13, lenticular nucleus: 14, external capsule: 1.5, claustrum; 777, motor center for in- ferior extreiuity ; 71', motor center for superior extremity ; V, motor center for face ; D, D, mo- tor fibers (red); E, sensory (blue); C, geniculate fibers (green). 26 A SYSTEM OF LEGAL MEDICINE. ^-i-r-rrn-S^f-fflffiEfpRht^ fj, ^..-T^'-T'^r^'xrr,.,^, Fig. 11. Showing the arterial supply at the base of the brain. (Testut.) 1, Internal carotid artery, divided at the opening of the cavernous sinus ; 2, anterior cere- bral artery: 3, middle cerebral artery and Sylvian artery; 4. choroid artery; .5, anterioi' com- municating artery; 6. posterior communicating artery; 7, posterior cerebral artery, with (70 its anterior. (7") its middle, and (7'") its posterior branches; 8, basilar artery; 9, superior cerebel- lar artery; 10, inferior and anterior cerebellar arteries; 11, bulbar arteries; 12, vertebral arte- ries; 13, inferior and posterior cerebellar arteries; 14, anterior spinal artery; a, anterior ex- tremity of inter-hemispherical fissure; ti, its posterior extremity; c, olfactive bulbs; d, optic commissure; e, pons; /, bulb; y, cerebellum. The left hemisphere of cerebellxim and right temporo-sphenoidal lobe have been removed. INSANITY IN ITS MEDICO-LEGAL BEAlUXdS. 27 and in the cortex or investing- gray matter we find the seat of that form of nervons action which is tlie direct output of celluhir functic^n. In some phxces are well-determined areas wliose special office is to originate definite motor impulses. Thanks to Hitzig-, Fritsch, Ferrier, and a host of other observers, we know that localized irritation of these will be fol- lowed by muscular contractions in distal parts, and. that these are of a uniform character, as can be repeatedly proved. We know that poste- riorly in the oc(npital lobes are located centers for vision ; that above in the parietal region is what is known as the angular gijrus, a center for the coordination of symbols that play a part in audition ; that anteriorly on the left side of the brain, at the foot of the third frontal convolution, is a center for speech, and that when destroyed the condition known as aphasia is a result ; that at the base of the brain anteriorly is a center for smell. These, as well as many others, have been located by experi- ment and proved to exist by the results of disease. What the exact location of the apparatus of vtind is has always been a matter of active dispute, although the great mass of testimony goes to show that it is the fore-])raiu which is concerned. In the light of exjjeri- ment and clinical observation this theory seems open to some question, and the views of Hugiilings- Jackson and Exner are less conservative and more i-easonable. I am therefore inclined to agree with them that no one part of the gray matter is alone concerned, but rather that mental action is the result of general and complex function. Figs. 2, 3, 4, 5, 6, 7, 8, 9, and 10, from Testut's admirable treatise {Traite d'Anafomie Hu- maine, etc., t. 2, Paris, 1S93), will enable the reader to more readily recog- nize the intricate system of communicatory or associative fibers in the brain itself, as well as those which pass eentrif ugally. The sensory organs and tracts that are engaged in the production of mind are extensive and intricate, and not only connect the concept, propositionizing, auditory, visual, and other sensory and motor centers which may be almost adjacent, but those as well which are more remote, and others form important tracts which are direct or commissural. Figs. 2, 3, 4, 5, diagrammaticaUy illus- trate the course of these fibers. Figs. 6, 7, 8, 9, 10, indicate the general connection of these with jjarts of the brain in which special functions are located ; Fig. 6 showing the entire lateral cortical surface of one hemi- sphere, with its function-zones mapped out and either represented in color or by limitmg lines, and Figs. 7, 8, 9, and ] 0, the association systems of the fore-brain. Fig. 11 shows the important basal ni-terial circulation of the brain, which is often subject to oltstructive changes or other dis- ease, especially in those forms of dementia consecutive to thrombosis, embohsm, or rupture from any other cause, the left middle cerebral artery being that most often involved. Kirchhoff {Handhooh of Insanifi/, p. 9) formulates the status of knowl- edge of localization regarding the deductions to be drawn from disease or non-development of the brain. He calls attention to the fact that : 1. "The interruption of certain systems of fibers leading from the cerebrum to the cerebellmn gives rise to distinct slowness and difficulty of the mental functions. 2. " The optic thalamus seems to possess more intimate relation to the higher mental functions than does the corpus striatum, inasmuch as the former alone undergoes atrophy in congenital absence of the cerebral hemisphereso 28 ^ SYSTE^I OF LEGAL MEDtCISE. 3. " The disturbance in the intellectual development of individuals in whom the corpus callosum is absent is very small, indicating that the higher mental processes are not dependent upon the frontal brain alone : indeed, in these cases the occipital lobes are mainly atroijlded. 4. " If the brain is imj^erfectly develojDcd as a whole, as in some idiots, there can be no question of localization, nor is any fui-ther conclusion warranted from irregular development in the cortical layers, unless it is cu'cumscribed." In illustration of this he alludes to the discovery of only narrow py- ramidal cells in the frontal lobes of a few idiots, which were so irregularly distributed that it was ahnost imjiossible to distinguish the layers. Here the imperfect mental de^^elopment may be attributed to the imperfect development of the frontal cortex. There appear to be no means of determining the seat of memory, but judging from the complex processes which operate in the formation of concepts, as weU as their diverse nature, it is probable that they are stored up in no particular locality ; in fact, the pathologj^ of dementia and its morbid anatomj' presume a jDrogTessive and general destructive change. MENTAL ELEMENTS — ^NORj\LyL, AND DISEASED. Au}^ extended consideration of physiological psychology in a book of this kind would be out of place, but it will suffice to state that the di\ds- ions of mind are three in number: feeling, which includes sensibOity and emotion ; thhdung, which inij^lies intellection or thought ; and volition, which is a result of the exercise of the fh'st two. These may be still fui-- ther amplified and subdivided. In the older definitions of mind it was the custom to speak of judgment, reason, and memoiy. but, after all. these may be better included under the head of " thinking.'' In the study of the normal as weU as of the diseased mind we are to consider perception, which implies the recognition and appreciation of the relations of sensation and the agencies which aff'ect the same. This means the recognition of the part played by the organs of special sense — the afferent nerves of conduction, the existence of groups of cells or nerve centers which receive the impressions from without, and the more imj^ortant condition of consciousness. The kind of intelligence which is necessary for the mensuration of the form and physical attriljutes of objects must be taken into account, especially when we come to consider the formation of hallucinations and iUusioiis. T\"lien a perception has been recognized and remembered, it becomes a concept or idea : and when comparison is made and the process of reasoning takes place, di judgment is arrived at. One of the most important mental faculties is that of memory, which enables the individual to retain and store up impressions, and which really forms the basis of the most important forms of higher mental ac- ti\dty. Memoiy may be said to be of two kinds — that which consists in the retention of perceptions or external impressions, and tliat which con- cerns the acknowledged recognition of self and the inner condition (or- ganic memory). Sensations of a personal kind are recognized and re- membered, and form the basis of self-api^reciation. Tliis latter form of memory, when affected, results in the change of the ego which is so ixsAXiry IX its mijdico-ijjcjl niiAniXiin. 29 niarked in some lialluciiiatoiy insanities. The ^Toupin*^ of eoneeijts or ideas, and their association, constitutes reasonin*^ and judgment, and precedes volition, which may be tlie demonstrative active expression of their conclusion. The degree of this manifestati(jn of course varies Ncrv much with the complexity and the extent of the nu-ntal operations wiiich are behind it; and it differs from reflex action in tlu; fact that the actixe demonstration is iiot governed by thought in the latter, l)ut is the result of a lively exteriial impression, which is si)inal in character, and the motor ex])ression uuiy or may not l)e attended by unconscious, cere- bration. The simplest f(jrm of retlex action nui}' be illustrated 1)y the rapid withdrawal of the finger from a hot surface, which produces actual phys- ical pain, the cause or degree of which is not weighed or estimated Ijy the mind, and the act itself is also too rapid to be a volitional one. Then, again, there are so-called instinctive reflex acts, where previous associa- tions and experiences enter into the causation of particular muscular contraction, and Avliere no apparent cons(;i(ms appreciation exists. The importance of the volitional act is, of course, gauged largel}' by the i)ar- ticjpation of reason and judgment, as well as the concurrence of affectiA'e feeling ; and we are presented in health and disease with numy gradations in the acts of will wliich begin as impulses and reach the dignity of elab- orate exercise of force after comparison, judgment, and discrimination have been operating. The capacity for inhil)ition, and, on the other hand, the influence of emotion and the absence of self-control, are to be considered. In the study of those conditions which suggest mental disease we are, of course, to ascertain, if possible, not only the previous life of the indi- vidual, but his environment and such causes as may have resulted in the mental degeneration. We are also to compare his mental expressions and conduct with that of others in the comnumity in which he may be livdng, to consider his training and education, and to go back, if possible, into the remote past, to discover what influence, if any, has been exerted upon his development as a result of the willful faults or involuntary mis- fortunes of his progenitors. Mental disease is not, as a rule, of sudden origin. There is nearly always some predisposition or some long-existing: cause, and in a very great many cases the process of mental dissoluti(.»n is a slow one and the departure from mental health is prolonged. This should be borne in mind, especially in the consideration of cases Avhich f(n-m the subject of legal inquiry ; but the poiwlar idea of insanity inipUes all sorts of possibilities and improbabilities which do not stand the test of clinical experience. Special Indications of Mental Weakness. Among the important evidences of mental deterioration ai*e Halluci- nations; Illusions and Delusions; Insistent and Imperative Concepts; Loss of Memory (both external and organic); Inharmonious Exercise of Ideation or Keasoning Power; Emotional Disturbance and Volitional Diminution or Exaggeration ; Physical Changes. 30 ^ SYSTEM OF LEGAL MEDICIXE. HALLUCIXATIOXS. An hallucination is a false perception, and in this respect differs from an illusion, by reason of the fact that the error leading to the crea- tion of the latter consists in the distortion of an objective thing. Hallu- cinations are of three kinds : First. Those due to a defect of the peripheral perceptive organ, or of the afferent nerves and centripetal fibers. Second. The form "o^hich includes examples of distui'bance of certain centi'al organs. Third. TMiere the disorder is chiefly confined to limited cortical areas. It has been held by some authors that it is possil)le to have hallucina- tions Trithout any cerebral partici2:)ation, or, in other words, any mental abeiTation, the organs of special sense themselves possessing a certain local memorj'. This seems to me to be a meretricious distinction and one "vrhoUy speculative, for the reason that it is impossible to have an hallucination without a previously formed concept, no matter how an- cient. Persons who become blind after a time may have visual halluci- nations, but those congenitally blind can, of course, have nothing of the kind, as no image has ever been projected upon the sensorium. It is important to consider hallucinations with regard to their pathog- eny : first, in connection with the organs of special sense themselves ; and second, where they are centrally originated, as a result of an irrita- tion and stimulus of certain Ijrain tracts where concej)ts have been stored lip. The simplest form of hallucination is that due to some local imtation or disease of one of the perceptive organs, and the false images need not necessarily be insane ; in fact, a variety of spiuious sensory images, without ol)jective basis, may be recognized by the individual as the re- sidt of disease or temporary disturbances of the cerebral circulation, he being a1>le to ajjpreciate their source, and it is only when the higher powers of the mind are so diseased that comparison and judgment fail to act as correctives, that the mental integrity of the individual is ques- tioned. All \'arieties of sensory- impression are likely to be perverted by causes which it is not necessar}' to mention here, except in a general way ; but we may consider the numerou;^ factors that may pervert the innervation of the important organs which serve to keep us in relation Avith the outsi ^■ world. It is not difficult to explain by purely jjliysi- cal agencies njiiny startling varieties of disturbed special sensation. Hallufinations are divided into visual, auditory, olfactirc, and ciitaneous. Visual hallucinations are largely dependent upon retinal phenom- ena, and are often connected with ischemia or disturbed circulation at the back of the eye. Tlje pulsation of the central arter\' or variations in the retinal light may give rise to rings or disks of light, dark spots, flashes, stars, or other scintilla, which may or not be used by a dis- eased brain as a basis for an elal)orate morbid concept association. Wliat other exjiansion there is of the mechanism which results in the misintcritretation of siin])le distal variations, I am unable to say. It would ajtpear, however, that a vei-y indift'erent form of peripheral stimu- lation will often start a train of disorderly thought at a time when in- hibition is not exerted. During the condition of sleep, when the upper IXSANITY JX ITS MKDirO-LKC.AL UKAUIXCS. 31 ■cortieal layers are inactive, the mere flasliinjj^ of a light before the ej-es of the sleeper is likely to produce complex dreams of fire and an unsys- tematized c(nuparison of concepts of some intricacy. There are some rules which govern the occurrence of peri})h('ral visual hallucinations, aiul one is that they are more pronounced when the eyes .are closed and in the dark, and they are more or less influenced ])y the <.'Oudition of the ocular muscles generall}'. According to Kirchhoff loc. cit., p. 48): "If the sensorial deception deveh»ps in one eye aloiu', the possibility of distinguishing- it from a unilateral hallucination which has developed centrally is to be sought in the fact that the central devel- opment gives rise to nuich more complicated phenomena." The explana- tion of a unilateral hallucination would naturally lead us to consider the X)hysiological pathology, and to look for some affection of the (X'cipital lobes. It has been i)ointed out that in paretic dementia in which the frontal lol)es are most frequently affected, there are seldom hallucina- tions ; but in those cases where tliis s^'mptom has occurred the occipital lobes have been found to be diseased. Unilateral halJucination of vision can be explained b}' some disease of the optic commissure, or of the nerve nuclei of one side of the brain. Auditory hallucinations, which may be of a very simple kind, or, on the other hand (as in the case of optical perversion), may form the basis of mental ndstakes, are varied in their causation and occurrence. They perhaps more frequently have a deeper and nu)re alarming signifi- cance than the others, are not so easily corrected, and are more gen- ■eral in occurrence than any other hallucinations. They usually consist -of the recognition of the sound of imaginary voices and the repetition of many ordinary sounds. A distinctly insane hallucination of hearing has nearly always valual)le diagnostic significance, for the reason that it in- dicates a more general derangement than those of the other senses. A person may readily have such a sane hallueination as hearing an imagi- nary voice, as the result, possildy, of an irritation of the middle ear; but the insane individual expresses his fear of the sounds of voices speaking through a telephoue, the register, or cracks in his room ; or, in a more disorderly conditiou, it is the figures in the pictures upon the wall who iire addressing him. Amlitovtj ]ial]i(ci)iafi(nis that convey' no suggestion of insanity, like all other ordinary false perceptions, are nearly always immediately re- moved, are recurrent in the original form, and, of course, are not associated with other evidences of derangement. The auditory halluci- nations of the insane patient form the basis of communications from divine personages, from invisible friends or others, who connuand him to perform various acts, and he cannot be convinced of his error even Avhen his environment is changed and certain objects are remo\'ed which facilitated the creation of the hallucination itself. There is a light grade of purely mental aiulitory hallucinatory disturbance that I have seen, and it is in some nieasm'c hysterical, the full inmge being called up at will, and the patient's declaration and be- havior doing away with any real su])position that the ear or eye is at fault. I have recently seen a case of tins kind, where the suspicion that an auditory hallucination existed was at first very strong, but frequent interviews convinced me that when the patient turned in one direction and -addressed an imaginary person, such an act was led up to by an incoher- 32 ^ SYSTi:2I OF LEGAL MEDICIXE. ent couversation, in wMcli tlie response to tlie imaginary mandate was- l^rompted by a pre\ious train of thonglit ; and when I asked her if the l^ersons she addressed were near her, she rephed, "No," but that she was- talking to them hi the spuit. The consequences of hallucinatory man- dates and subsequent delusions are apt to sometimes be serious, and those cases where patients refuse food and drink because they are toki to do so liy imagiuar}- persons are often obliged to submit to compulsory feedmg, or, if this is not done, death by starvation ensues. Hallucinator}^ voices may be bilateral or unilateral, external or inter- nal, and are not so common at night as in the daytime when the patient is awake. Olfactive hallucinations are exceedingly rare, and may, like the others, have a local or a central basis. Perversions of both taste and smell, therefore, may result from some actual local condition, such as decomposition of epithehum in the mouth, bad taste, offensive discharges,. etc. Sometimes these conditions lead to well-marked delusions, which are amplified usually in the direction of the horrible. The odor of decayed matter suggests that of a dead bod}', Avhile re- fusal to eat is the result of a delusion of poisoning. There are a class of purely central hallucinations of this character which owe their origin to some disease of the oKactory nerve itself, or probably to the uncinate gji-us. Such a case I have elsewhere reported, where occasionally hallu- cinatoiy perception of the odor of smoke was a symptom, and a sub- sequent autopsy revealed extensive disease of the region above mentioned. However, the patient is nearh^ always able to recognize the source of his trouble ; but when he does not, we may then account for such a per\-er- sion as an incident due to insanity. What are known as hallucinations of feeling, and what are really per- verted or false perceptions of the skin and its appendages, the visceral organs, or an alteration of what is known as the muscular sense, are s^Tiiptoms both of the lighter psychoses as well as of the graver forms- of mental disease, and, Hke the other hallucinations previous^ mentioned, maj^ not at tunes be attended by any considerable intellectual impair- ment. They play an important part in hjqjochondi-iasis, and in that affection of Ihnited intellectual disturbance known as piiranoia, where one or two dominant illusions exist. Theii' range, however, is usually very wide. Distnrhances of muscular sense lead to a variety of perverted percep- tions, indi\iduals declaring that they have been depris'ed of certain mem- bers, or that one part of the body or the other is al)sent. A common ex- ample of this form of hallucuiation is that in which the individual who has imdergone anii^utation declares that he feels the presence of the lost limb. Sometimes these hallucinations are pleasiu-able and expansive, thougli very often they are associated Avith mental distress and not un- rareh- lead to suicide. They very often cause the victim to declare that he is being subjected to some occult influence, that he is being mesmer- ized, or is the subject of punishment inflicted by others. Of course, under these circumstances, the halhieination is the basis of a delusion. Seasoned hdJJucinafions sometimes have an important significance in the form of sexual perversion. Curious cases are recorded where women prefer the most absurd charges of assault, or imagine themselves impregnated or sexual!}^ de- jysjyiTV IX ITS mi:divu-li:(ial ukakixcs. 33 formed, as the result of sensorial hallueinations. I liave seen several men "svho tlironi>'li siieli a derang'ed mental state believed themselves i)ref^'nant. As l)efoi-e stated, the exi)i'ession of hallucinations of all kinds is very irreut are expressed at night, when the patient is alone, and when sleep is fitful, and the insane person indulges in noisy outbreaks. As Lewis {A Text-hool- of Menial Diseases:, p. 1G7) has pointed out, such indiA'iduals are benefited by removal to an associate dormitory. " Such hallucinations," says he, " often peculiarly vivify and fascinate the mental vision, and, according to their nature, call iov{\\ correspond- ing results. The patient may be passionate, wild, threatening, and defiant, shouting an alarm for succor; joyous, exultant, or in a l)oisterous merriment. Every phase of emotional life may present itself as the hal- lucinations varv and he enacts his little drama alone. ... In general 34 A SYSTEM OF LEGAL MEDICLXE. paralysis these noetnrnal orgies are frequent, noisy, i-estless, with or mth- out hallucination, aecompanpug the latter stages of most cases." A talkie prepared by Dr. Edward B. Lane is reproduced, which mil l">e of service in showing not only the kind and extent of hallucinations, but the forais of insanity in which they aj^pear. {Boston Medical and Surgical Journal, vol. cxxv., Xo. 11, p. 268.) 1 1 Si^ ■« rfS .^ 1 1 B ^. « . <>2 ^-' E-i ^i- ^ ^ s S S C3 t 1 t ^■ ^ s !> «S & 1^ 8 [Ss s i ■| s- t 2 fc: to 9 4 f) 55 ' ' mania 15 3 20 38 Pai'etic dementia C) 2 1 3 19 34 Post-paralytic insanity 1 2 7 10 Other organic brain disease 3 2 "1 6. Epileptic insanity 4 4 8- Insanity of pubescence 4 2 11 Katatonia 2 4 Hysterical insanitj' 1 5 6. Senile insanity fi 5 16 '^9 Alcoholic insanity 1 _; 2 3^ KecuiTent mania 1 3 4 Folic du doiite 1 1 Simple mania 2 2' " melancholia 10 10 Folic circiilairc 7 ( Senile dementia •• 6 6 114 19 o 47 10 2 1 1 105 301 The appearance of hallucinations in primary delusional insanity has- been referred to, and in such a condition they are usually persistent, and form a basis of that variety kno^vn as the sensorielle YerriicWieit, in which some delusions owe their origin to perverted perceptions originating in the skin or the ^dsceral organs. In other cases, delusions of persecution and susiDicion spring directly from hallucinations of hearing and seeing. ILLUSIONS. An illusion is a distorted percei^tion of an objective reahty ; in other words, it is the false i)ercei3ti(ni of something that has an existence. Illusions are like hallucinations in their classification — they may be of various kinds, and are due largely to local disease ; and while some- times as elements of insanity they are l\y no means so important as the forms of false perceptifju just descril)ed, Avhicli have no objective basis, may originate more or less stul)boru delusions, or, on the other liand, may often lie easily corrected l)y their possessor. The distinction between an illusion and hallucination may be illus- * And touch. 7XSJ.\77T IX ITS MKDira-LKdAL Jli:Ji;iXGS. 35 trated as follows : if a person looks at a tree and sees two, it is an illnsion ; if he declares that he sees a tree where none exists, it is an hallneination. If he niisinterpi'ets the sound of a rin<;inu- bell, it is an illusion ; if he says that he hears a bell when none has rung-, it is an hallucination. Psyeluj- logically, the processes consist in the inability to coin})reliend the nature of a physical inipressicni, an imperfect concept beinj>: the result of a false perception upon which an imperfect judgment has been passed. In an hypnotic condition or one of exagg-erated receptivity, an indi- vidual is very apt to make illusional mistakes in identity, which would be out of the question under other circumstances ; so that it is not un- usual for insane peoi)le to eventiudly have distinct delusions of person- ality, which are due to their false ai)})reciation of the figure and form of some person wlioni they have possibly never seen before. Like halluchui- tions, illusions are common in alcoholic insanity, as well as in paranoia and coufusional insanity, and sometimes exist as a symptom of paretic dementia. DELUSIONS. A delusion is a false belief, and nuiy be regarded as sane and insane. Under the former head are grouped all forms of eiToueous or unusual beliefs which many individuals entei-tain whose mental integrity is un- questioned. These latter may be simply the offspring of ignorance or prejudice or misinformation, and unless they be the fruit of religious or other dognuis may be easily removed l)y sufficient evidence. When be- liefs are held wliich to nuiny seem unreasonable, l^ut are nevertheless shared by a sufficient number of people to be simply matters of faitli, they still need not be the product of diseased reasoning, though often- times the}^ are eccentric and troublesome to the world at large. No one would think of questioning the. mental health of the large rehgious sects that believe in the immaculate conception or the miracles of Roman Catholicism, the doctrine of Swedeuborgianism or spiritualism, any more than they would the sincerity of a great majority who hold to any other faith the elements of which are mor<^ or less inexplicable. It is, however, when extravagant belief obtains such complete possession, or is connected with clearly erratic behavi(n-, that our doubts of the sul)ject's sanity arise. So long as the spirit}ualist has or pretends to have com- munication w4th visible spirits, and so long as his hallucinations or illu- sions or delusions do not tincture his conduct in a way that makes him a nuisance to his fellows, the law concerns itself but "httle ; Init Avhen, as the result of a delusion, a crime is connnitted or a foolish business act is (umsummated, we more seriously ([uestion his responsibility. The law is exceedingly merciful, if not lax, in its attitude toward such individ- uals, and is disposed to accept excuses that may be offered as a defense. I can recall a case where a large amount of money had been left by an eccentric Frenchnuin to a philanthropic society for the suppression of cruelt}' to auinuds, and for the s])ecial care of eats.* His will was con- tested, and liesides peculiarities of manner, it was the subject of contest by reason of this seeming nuirk of insanity. It, however, transpired that the testator had been tov years a consistent l)eliever in metempsychosis, and was, naturally, anxious that his transferred soul should l)e well taken care of after his demise. * Tlio Bonavd Will Case. 36 ^ SYSTEM OF LEGAL MEDICLXE. In Catliolie countries, where large nnmbers of people believe in visions and miracles — such belief oftentimes being primarily based upon the donbtfiil testimony of a hysterical girl or some equally unrehable ol)- server — it does not do to too closely qnestion what most of the world wonld consider delnsions. In a fnture time, when the stndy of the gen- esis of religions belief is more thorongh than it now is, and when pathol- ogists and psychologists are brave enough to consider the sn])ject from a material standpoint, much of the present uncertainty will be removed, and it will be possible to estimate the mental integrity and illogical organization not only of many existing forms of faith, bnt of the new and hastily digested varieties of fashionable religion that crop to the sm'face from time to time and are little more than vents for those in search of notoriety or of emotional excitement to find relief. I am in possession of a large amount of manuscript which throws a good deal of light upon this subject, and I think my exiDcrience is shared by other students of mental medicine, namely, that much that is accepted by rep- resentative behevers who are searching for sensations has its origin in the insane asylums. In this connection I append the statement of a paranoiac patient, whose theories are explained by his disease. This man, like others, lived for some time in a community mthout attracting attention to his real state, and found sjanpathizers and believers. In acfiordanee with j-oui' expressed wisli that I wi'ite yon a statement of events in my life which happened from the time of my retin-n from Europe, February 7, 1876, until the present time, January 6, 1878, 1 i^roceed as follows. I will freshen yoiir recol- lection by brief reference to the chief points of my education up to the beginning of this time. Earl}' home training and general schooling usual for Christian families. General university study. Graduation in Medical Department. I went to , opened an office in one of the best buildings there, lived at the best hotel, boarded a valuable team which had been presented to me, and my expenses ran $150 per month, only, as I supposed, consistent with my reasonable expectations on the education, and my at least presumable professional attainments. I ijursued the usual course among people — went to church, extended my acquaintance, did some iDrofessional business about the hotel among Christians and Jews, had one or two misunderstandings on the matter of charges (verj- unpleasant to me). Received scarcely any business from the city, though my card was very conspicuous in the city column of the daily paper — simply name, residence, office, and telephone nimiber. I met several of the best citizens. At the hotel at this time a gentleman, evidently one of the best citizens, was living. I saw him, and rememljer of thinking at the time, " Now, tliere is one of the best citizens ; he can ax^preciate my merits, so I will not crowd myself upon liim." In tlie dining-room of the hotel I happened to be seated full face to the entrance, but a goodly distance away. Times were active, and man^^ people came in and out. One noon a young and stately lady came in, a young gentleman beside lier (her brother). I noticed strangely apparent evidences of her disposition for me — this upon several occasions — so much so that one daj' I placed my glasses on to scrutinize her closely. After two or three manifestations of her preferment I noticed her in company with her mother (a lady, to my mind, of the right tj-pe) ; then the gentleman mentioned before as a respectable citizen living at the hotel was with her. It now became ajiparent they were all of one family — father, mother, daughter, and two brothers. Of all I liked the appearance and conduct. The yoimg lady's expressions went on ; then I fell in love with her. The passion grew upon me, possessed me, ran away with me. At approaching Christmas I sent her, before having met lier, a large basket of flowers with my name down in tiie middle of them. These the mother returned, saying on a note she could not allow her daughter to receive presents from gentlemen with whom she was unaccpiainted. But before this I had met the fatlier and asked him for an introduction to the family. I sent a card and called, met tlie mother and brothers, but a meeting with the daughter wa-j prevented — evidently until they sliould satisfy themselves from others' say-so as to me: who, wliat, whence, value, etc., etc. The girl seemed to me the entire fulfill- ment of all my early-life impressions, and all my desires might ask. I loved her in- JXSAXITY IX ITS MKDlCO-LKdAL JU:.H;i.\(!S. 37 tensely. In this love my ileveloi)moiit was completed. I ■wrote llie mother several times to introduce ns, but was not ji^nititied. I thought, too, they favored our atTec- tions, and I supposed tlieir mctliod would b(> tlieir own ; and ])robably a party at their house, or at that of a frieml's family also at that tiiiic at tlic hotel, but pieseiitly to move into an home. The family with the young lady moveil from the hotel into their home in the city. We were thus estranged. Anotiier family, friends of theirs, came to the hotel, as I believed, to encourage me meeting them. Tliis I wouiil not do by finy volition of my own. I was resolved if they had anything to say they must say it in unmistakable language, for by now I was out of all .sympathy with them at their inhunuin conduct, but still loved the daughter. The season at came on. I con- tinued my ofKce in the city, and by appointment of the manager of the Hotel I kept hours thei'e too, it being but a half-hour's run between. At another family, friends of the first, came to the lake. I met none of them as it hapi)ened. My young lady came out to visit them. I wrote her, asking privilege to meet iier; got no reply. Asked an interview with the old lady she was visiting; got it, explained tjie situation, and asked lier for an introduction to the young lady. She thought it would be Avrong, as she was their guest. The next day they went boating ; came direct from the lake to their train, where the young lady's mother received her and took her to the city. The old lady at the lake then advised me to see the young lady at her home or write her, and to do so at once. Accordingly 1 wrote her fully, the season at the lake being •ended. I got no answer, but a brother came next day to the hotel and dined with their friends. Next day the j'oung lady came. By this time, the proceeds of business not having been up to exjiectations, I was being closed down upon by creditors. A friend u})on whom I had i-elied came and helped me out, and refused to coiiperate with me in any further operations in . I would not leave without an expression from this young lady. My friend went to the father for tliis, and In-ouglit me word that the young lady despised me. I then, much oppressed, had nothing to do but to go away. I went to Jonestown. In Jonestown I opened an office, resolved now at all hazards to be independent of any one. I was thirty years of age, and determined to make my profession support me now, or starve out of it into something else or into death. After so much educa- tion and so many anxieties, I resolved I would prefer death rather than be on any one's charity, and besides felt that educational impressions had not confirmed and verified themselves. I went on, managed to live also in my office — one room — reduced expenses to $4.5 a month, went to chiu-ch, and extended acquaintance. Notwithstand- ing all this I had to borrow money. I borrowed of some Jews doing business in the same building, at a high percent. I made some money, and was getting on pretty well, and was being encouraged by the leading physician of Jonestown. I paid my rent according to statutory requirements and consistent with the tmderstanding. However, I was peremptorily summoned to court (illegally, as I can show) for balance of rent and possession of the place. At the justices' court I presented my case (being too poor to obligate myself to a lawyer). It seemed a simple case of rights, and I was •confident. However, a judgment was given against me — an unholy and an unright- eous judgment, as I can shoir. The officers, a few days later, came down on me for the rent and possession given in the judgment. I paid the rent then np seA"enteen rietor had himself been, as iu^ from time to tinu^ had told nu', a '"Western tough "—I sat dowji the night before the day I in- tended to proceed, and wrote out my position, intention, and referred to possible re- sults, also stating my beliefs in religion, views on God, conclusions on my life up to 38 J. SYSTEM OF LEGAL MEDICLXE. this time, and changes in opinions on these suljjects I thought it desirable should be made. I outlined these only briefly, as I did not have time to elaborate, saving if I fell I might desire to see these things done by others. If I died I knevr tliis would be found in my desk. Next morning I went with a receipt for $20. also a golden eagle. and a lease* for six months. I laid down the money and receipt before the proprietoi" of the building, on his desk in his office. Said I. " There is Jf20 and a receipt for it ; sign that." He took it, looked at it. and said, " Well, I don't hare to if I don't want to.'' Said I. "Yes. you do.'' and "covered" his face with a 38-ealiber I'evolver (S. & W.). He exclaimed. '• Well I " I saw he hesitated, and I must unnerve him. I raised the gun over his head and fii-ed iu the brick wall, high up. Tliis brought him and two other men. who were in the office at the same time, to their feet. The two others came toward me. and I supposed would seize me, so I "'pulled down "" on them, held them at bay. and annotmced, "He"s got to sign that receipt."" He, meantime, was exclaiming." "I'll sign it I 111 sign it I "' and he sat down and did sign it. He got up and handed it to me. I then gave him the lease ; he took it. I said, " There is a lease for six months ; sign that."' "I'll sign it ! '" he said. He did so. I then emptied the pistol in his waUs, excepting one ball. This I did because I knew the facts would come out. and as an evidence of no more use for such forces ; to show only those ends may be attained by war which may be reached by peaceful, honorable means among fully accomplished men. The fifth and last ball I discharged at my office door, near my (lovely) neighbor, to show him all the forces to be considered in such foul designs as his ; but while we had them we also knew how to control and dii-ect them, but could reach our ends and prove our course if given a fair chance. I now went to sell the lease, to increase its possible value, and intended to sell at almost any figure. The value was $90. Wlien I came to the street cries of " There he is ! take him ! kill him I " etc.. etc., were expressed. I was arrested, taken to the police-station ; the jn-oprietors swore in a charge of assault with intent to kill. I explained it was not so — I only had insisted on his signature. One gentleman spoke up and said. '• Hello. Doctor, what's the matter?"' This gentleman was a ilr. Z , a Jew. The officers took me, locked me in a cell. Mr. Z protested, and said he would go my bail. They fixed iip the yjapers. I was taken to coui-t. The charge was read. I denied it. Bail was fixed at $750. Mr. Z signed the certificate, and trial was set for a hearing next day. I was released. The widt for ejectment was served on me Good Friday. I refused to leave my office. The officers said they would not act '•until to-morrow at eleven o'clock.'" At that time they came. I refused to go, and the officers di'agged me from my office. thus using their execution in spite of me. I was taken to the hospital, where I agreed to stay until the Iwnd could be changed. This was extended indefinitely by ili'. Z signing a new bond to which my fi'iend also affixed his signature, he having been sum- moned by wire. While at the hosj^ital Easter Sunday I desired to go to church, luit was not allowed to. By extension of the bond, and the deductions I wished to an- nounce from all this treatment. I have come on to Xew York City. I shall return to Jonestown for my trial. My execution in the M-rit of the landlord was served and exe- cuted at a remarkable time of the Christian year. viz.. Good Friday. I was dragged away on the .Je'^^■ish Smiday; refused attendance on chui'ch Easter Sunday. Yester- day I issued the following proclamation to the young ladies of Jonestown : " I call yotir attention to the treatment I have received at the hands of the Christians, and how differently the .Jews have treated me. I call upon yotx to demand of yom- daily papers an open statement of the facts. I recommend you, unless the Jews are ad- mitted to full acknowledgment and given fidl and equal share iu all the joy of yotir coming Easter celebrations — I recommend you not to dance."' (They are getting up an elaborate dance.) Xow, you will notice the contrast of ti-eatment which I have received from Jews and Chi-istians — an equal stranger to both. Deductions : that defect of teaching in religion prevented me meeting the young lady of E ; these defects, as medical men. we know: I refer to the technicalities and rites of the church — mystery of incarnation, resurrection. Adam and Eve, and such teachings out of harmony with natm-e and with fact, and wrong, leading us rapidly into dangers, if not national ca- lamity. These dangers are not, of coiirse, now pai-ticularly threatening. I tried Christianity luider the old cross, and found but half a Christ and lost salvation, I do not relinquish Christianity, but in keeping it insist on changes, and don't want salva- tion without the Jews, for I think they for 1878 years have held their position against the unnatural conception, and liaA-e been the ^^ctims of mucli persecutioii which tlie h\-pocrisies of Cliristianity as now interjireted are responsible for. and it is time these things stop. This virtually brings us about up to date, and tlie elaboration of the de- tails respecting changes ^vill be made in due time. When I left Jonestown I promised IXSJyfTV IX ITS MEDKO-LKdAL BEARINGS. 3^ to the Jews, throiif?li my friend Dr. K , my body, soul, and powers. I shall do wliat I can to my pui-poses, iind whether tlie Jews ac<'e])t the otter or not remains to be seen. If so I sliall unite tlie Jews witli Christianity in tlesh and blood under tlie new cross. As I told you, our niune is Christians of tlie Starred Cross. I realize this is but a beginning, but everything must start so and grow. Before this was written he had perfected a complete scheme of what he intended to do, liad ordered special badges, one of which he wore, and perfected the details of this new " Keliii'ion of the Starred Cross.-' The case is reproduced in full liecausi; I Ix'lieve it shows most fidly the gene- sis of a state characterized l>y significant ercjtic, persecutory, (pierulent, and religious insane delusions which are so often associated in cases which find their way into the courts, and where juries lose sight of their real nature, considering the education and ordinary behavior of the lunatifi. Without pursuing this suT)ject at length, I may refer to the teachings^ of Ltttlier and Swedenborg and other fanatics, whose lives were filled with plentiful instances of the same behavior. Insane delusions are those which concern us most directly. An in- sane delusion implies the holding of a belief in something which has no existence except in the diseased imagination of a person, and which is not removable by satisfactory evidence of its falsit}-. Other definitions have been given, but I think this will do for practical use. Spitzka [In- mnifj/, etc., p. 24) calls insane delusions ''faulty ideas growing oat of a l)erversion or weakening of the logical apparatus." Delusions are the outgrowth of a mental disorganization wliicli is usually far-reaching and impli(_'S a certain involution of the mental processes. They may l)e ec- centric and centric, dejiending in the fii'st instance upon hallucinations or illusions or false appreciation of external objects, or they may be en- tirely connected with the subjective condition, the identity becoming lost or confused. They may exist severally, together, or there may be one more or less dominant delusion which is repeatedly and consistently ex- pressed. They may, of course, be ex})ressed in speech or shown in man- ner, gesture, and dress. They may be h^gically manifested as the result of a more or less common train of reasoning with false premises (sys- tematized delusions), or they may be disorderly, confused, and entirely devoid of plausibility (unsystematized). The first very often go with astonishing vigor of intellectual power and capacity for analysis, such as we often find in reasoning insanity, but the conclusions, judgment, and volition are impaired. The disorderly or unsystematized delusions are much more dramatic and betray an acute denun-alization. A systematized delusion has s(une basis, and the dilference between this and the other kind may be illustrated by calling attention to the fact that in the former the possessor of a delusion of suspicion or per- secution may pick out some particular i)erson as his imaginary enemy, giving reasons for the alleged persecution — ])ossibly connecting the enemy with them — and is full of reasons for his mental attitiule wliich are nun-e or less plausible ; while the possessor of the unsystematized delusion makes the vagiu\^t and wildest accusations, complaining of ])er- sons concealed in the water-})ii)es, referring to the voices of imaginary enemies who are cursing him, and seems to have no basis whatever for his absurd Ix'lief. Systematized delusions are usually limited in number, and belong to 40 ^ SYSTEM OF LEGAL MEDICINE. the evolutional insanities, wliich include such affections as paranoia; while unsystematized delusions are usually plentiful, and are very often accompanied by the incoherence which helong's to the acquii'ed and so- matic insanities or to the involutional jisychoses, which include paresis^ and dementia. The genesis of an insane delusion bears a proportionate relation to the failure of the object-consciousness, while the subject-consciousness is exerted; as Lewis ijoc. cH., pp. 126, 127) expresses it: "As subject-con- sciousness becomes more and more pronoimced, with failiu-e of object- oonsciousness, all impressions ahke, received from the non-eg'O, become the pabulum for the growth of an all-pervading egoism. The subject broods over his multiform and novel feelings — morbid introspection and egoistic musings replace the healthy altruistic feelings and sentiments, and, since the emotional life is itself in i3art the origin of rej)resentative cognitions of the outer cosmos, so out of this soiu'ce there now arise falsifications of the enwonment. " We have been tracing in these mental operations the transformation of the euAdronment to the ahen's mind : out of the old tissue, by a species of rearrangement and reconstruction, is woven a fabric representing to him the reahty of external things, and which to him is the only reality, but to his former state of sanity is an utter falsification. Since the morbid eoncej)t is projected out as the actual cosmos, and since internal order must correspond to the external, so a transformation of the ego itself resjDonds to this altered state — the former identity is lost and re- placed by the new. " And here we have an explication of that newly acquired freedom which, at this juncture, aj)pears to dawn upon the mind of the monoma- niac. No longer are phenomena in the outer world laboriously investi- gated and subordinated to rigid laws of logic and of science — they pass, as through a magic crucible, the morbid tissue of his brain, and are trans- formed in accordance with no objective laws, but take their color wholly from the morbid emotional states present. Self-creations arise with wondrous celerity and of protean form ; and the morbid imagination con- jures up fantastic groupings utterly devoid of coherence and objective reality. A feeling of new freedom replaces the old one of restriction and aggression by the en^dronment, and the ego is consequently endowed with new faculties, new powers — becomes a mighty potentate or a god. Still the environment is indelibly stamped ^x^\l the malign character which the former emotional state fostered, and it is only in late stages of the malady that such realization of a new-got freedom entirely effaces the enmity of the non-ego from the mind." The importance of delusion as a symptom of insanity cannot lie too strongly held. It is the most conspicuous and least easily misunderstood embodiment of intellectual perversion, and therefore has been the strong- est element in the formation of medico-legal tests. There are few defi- nite insanities in which at some time or another it is not manifest, and it always involves the distortion or unconsciousness of self. All other sorts of aberrations enter in its production, and it is active and retro- active ; and it is only when the power to recall concepts is destroyed that this impression of insanity is absent. Insane delusions are, as a rule, strengthened by false adductions of proof — the natural result of a disordered perception ; and their tendency JXSJXITY IX ITS MEDirO-LECAL liKAIilXG.S. 41 is to l)e(!()iiie more and more inisysteniatized. Trivial and oftentimes absurd liappenings will be seized upon by the patient and dig'nilied to tlie positi(m of corroborative proof. No better example of Mliat I have said can he presented than the case of a patient Avho, while insane, came from Chicafi-o to New Yoi-k l)y rail, and whose journal thus gTaphically reproduces her insajie hallucinations, illusions, and delusions : Extfurt of Jonnidl. Left, Chicago by tlie 8.15 Gmiul Trunk Kaihvay. falling ^Irs. D good-by, but adding that I did not mean to do 8o to the rest; that she would hear from me again, as but for her I wouhl have enjoyed little rest at night — and so I do mean to wi'ite to her. On entering the car I immediately perceived one old man and one old Avoman. who coughed loudly and sent a meaning, too, and toward the man in front of me, and from this conversation I gathered (which took place in German, directed toward a fat, vulgar woman on the left) : "She has got to go through with it, because we've got to get paid. Have you gone through the other car?" "No," replied the woman. "I'll leave it to j'ou to work through it — that's all right." A meaning nod and look of assent was exchanged by the conductor, and a woman behind me rose to look at me, nodded assent to the old man, who laughed and grinned, conspieiiously cleared his throat, as much as to say, " You've got to pay us." In enters a short, thick-set man with a black- silk cap. I believe he is the friend of the dark, tall man I recognized before in Chicago, so I knew well what to expect. About three o'clock at night I heard a lady opposite me, on a line with me, say: "That lady's head must be aching — she has not changed her position from the time she entered the car." The man in front of me, avIio carried on the conversation before in German to the woman, said (he was not the same man who sat there fir.'it when I entered the ear) : "You see, they're on the lookout. We'll get so and so to stand in front of her so sho can't see her, and a string of them to pass from the next car, and that'll make it all right." And true enough a i>rocession passed, each nodding assent, and the old man conspicuously again cleared his throat. I got up then and asked the lady who had mentioned almost my not stirring to sit with her, told her the conversation I overheard, and as I was traveling alone I should be so much o1>liged to sit with her Tintil she left the car, to which she kindly assented. The car was filled Avith a low lot of German emigrants and detectives I had recognized from Chicago. Near Hamilton I overheard one say, " She's paid her ; now she must share with us." When we left Hamilton I asked a nice, kind-looking lady from Little Falls, Mrs. L , permission to sit with her ; she was so kind, thanks to her. Kude glances and smacks. Even while talking to her, a woman deliberately knocked me. and on entering the car at Suspension Bridge it took all of my agility to evade a premedi- tated encounter from a man with a gray overcoat. A charming lady dressed in mourn- ing entered the car, and I did enjoy my talk with her — so refreshing after the hard crowd I had been thrown with — and was so sorry when we parted in Buffalo, where I took the buss and changed for New York Central. As I waited at the station I asked the nicest-looking lady in the waiting-room to sit with her until she reached New York, and she readily assented ; but I changed my mind, for, to my horror, I saw that same detective of Chicago with the black cap say to her that he had his bet on, "and you must share with us ; she's paid the others, and she will you ;"' and a nod of assent fol- lowed, and a quieting inHueiice sjiread over all the German emigrants who had accom- panied me from Chicago, and the vulgar woman and the Avife of the old man said, •• Of course she's got to pay — we'll niak-c her ; Ave'U run her out of New York, just as they did out of Chicago ; irv work that game better than they do : Ave've got some of their own men on our side.'' So, seeing a nice-looking lady behind me Avith a dog. I de- termined upon taking a palace- car, paying for my sleeper, but sitting in it, and fol- loAved the nice-looking lady in the palace-car, Avho Avas followed by an old gentleman who crossly insisted upon keeping her dog. The old gentleman left her and a dashy- looking one gave her a note to read in the car, sat by her. When he left I joined her. but I perceived after talking to her aAvhile a marked reserve and coolness Avhich I had not observed before she spoke to the man. On the contrary; and her eyes Avere fixed toAvard a man, as seA'eral at the back of us, and I saAv a forced manner in her toAvard me Avas the result, and I understood, by a glance to the man in a line Avith us. that they had struck a bargain. The porter came, and I told him I Avished to sit up all night, and I Avould pay him for my berth, as I did not Avish to enter the car Avith the 42 ^ SYSTEM OF LEGAL^ MEDICIXE. low German emigi-ants. He said, "All the berths are taken." "Well," I said, "then find nie a seat in another ear." " Well," was his rejjly, "Ave'll sfe what we can do for 3"ou," and off he went. The man on a line calls him : " Plere are fi^-e dollars for you ! " "Yes, sir." The gentleman raised his finger: "Now you stick to it," and a nod of assent. Up he comes to me and asks for my ticket. I give it to him out of the bag, and instead of his retui'ning it into my outstretched hand he puts it in vay lap. Tlie nod previous had made me suspicious of him, and 1 thought of asking the lady to take the ticket, but thought, "Surely she will think me crank}-," and picked it up, and at once .s-cnf the nod of assent on the lad)^ opposite directed toward the gentleman who had jjaid the man the five dollars, and looking at him; he meant, " JS'oiv you can say you saw her do it, and una- /understand the whole business." The lady got up and changed her seat, and the jjorter, in an insinuating way, at once joined me, and said he could* give me a berth above the lady. I told him I did not wish one, and at once got up and joined the lady on the other side. He followed me and said, "I can let you sit up, if you wish, down there, but it will cost you seven dollars." At once I saw tlirough the whole btisiness. He wished my seven dollars to cover the man's five dollars to whom he winked, so I firmly said I had no idea of paying that — to take me to the other ■ear at once ; and so I left, and he put me among the Gierman emigrants, saying I was " crazy." The fact is, he Avas mad I had fooled them, and though I knew I would have a rough time of it, I determined to jalace myself in God's hands. After finding out the lady who first spoke to me in the waiting-room I asked her to be with me until we reached New York, and I took the end seat in the car, which was very uncomfortable. After a while a string of men jjassed, just as they did when I left Chicago. The man cleared his throat, all nodded in procession, and a low fellow in an impudent manner reclined on the side seat. I immediatelj^ changed mine, and asked to occupy the one facing the lady, to which she assented. Immediately the man with the cap came up and said something very earnestly to her I could not hear. She got up ; a string — three — of men closed in upon me, and looked awful nasty and vulgar. I closed my eyes. The same performance took place in the night several times in the presence of the lady, who told me she left in the Weisland ; and my only salvation was in turning around, closing my eyes, and saying, " Now I lay me down to sleep." What else could I do? Who else could help me? Toward 6 a.m. the vulgar woman said in German, "I trap geld" — it means fine, pay for punishment. Of coitrse I pricked up my ears. " We's got her," said another. " Now we'll liave her up and make her pay ;" and I saw two grim-looking men opi^osite me. They looked like farmers, very fierce. I thought to myself, "I'd like to sec you dare lay youi- hands upon me; I'd make it hot for some of you rascals." The manifestation of delusions, of coui'se, bears a direct relation to the particular form of insanity, and their development is largel}^ depend- ent upon the habits of life, environineut, and cause of the mental dis- ease, as well as the emotional activity at the time. There ai-e depressed, expansive, grandiose, erotic, religious, and hypochondriacal delusions, the latter being chiefly suljjective, i.e., sensorial. They vary from time to time, are subject to many influences, and are more or less tenaciously held. What is known as a fixed delusion is one of a dominant charac- ter, which is obstiuately entertained and rarely changed in any way, and forming the conspicuous symptom of the insanity. "VMiat are known as concealed delusions are those which are sup- pressed, tlie luiuxtic preserving, when occasion requires, so much self-con- trol that it is impossible to extort from him liis insane false belief , which, however, at other times he expresses very freely. It is very common, as I liave said, for people with limited delusions to present little or nothing wliich draws attention to their real condition, such subjects being gen- erally well behaved. These are the cases that lead to controversies in court and often end in the discomfiture of the physician. With free- dom in vieAV, the clever lunatic can T)e so aroused and on the alert as to deceive every one about him, and he is trium}>liantly discharged as an injured person. I can recall many instances of this kind which are JX.SJXITY IX ITS MKDlCO-LKdAL liKAIUXdS. 43 more or less dramatic, and one in ])articular whei-e llie delusion was of a re]iodies. I exam- ined him and found the well-marked synq)toms of early paretic dementia. He had delusions of power, and a confidence in his own Cii])a1)ility as a reformer that was refreshing. His theory in regard to the immac- ulate conception was that it was through a kiss, and he proposed to do away with the ordinary method of intercourse and substitute a ])lan of his own which was in every way to be more pure. The patient was liberated upon application of a lawyer who was one of the strongest agitators in the mov(Mnent which was directed to open the doors of lunatic asylums, and his interest in his client was very great. He, how- ever, received a rude check when he presented his bill for professional services and the client procecnled to issue l)t)nds and })ank-notes for its liayment, Avhicli he made with a pen and whatever scraps of paper he eould lay his hands upon. This man has since committed suicide. Instances of this kind could be multii)lied. and these two examples are brought forward to show how easy it is to be mistaken, and to direct the attention of judges and jurors to the necessity for prolonged Avateli- 44 ^ SYSTEM OF LEGAL MEDICINE. ing and tlie applicatiou of tests which must be more satisfactoiy than those ordinarily employed. Spitzka calls attention to the fact that the possessor of those systematized delusions which relate to social and polit- ical ambition, as a rule, jDOSsesses a higher intellectual activity than the holder of erotic and religious insane falsv? beliefs. It is certain that the former, who are ver^- numerous and usually behave themselves, comjiar- atively, so well that thej^ keep outside of the walls of the asylums, are often simply recognized as " cranks." The erotic and religious delusions are more apt to be manifested by the possessors of acquired acute insanity. Systematized erotic and relig- ious delusions are apt to be entertained by the same person, and spring more or less from each other. The erotic belief is often pure and has relation to abstract things, and is not connected with emotional excite- ment of a physical kind, though its genesis m.ay dej)end ujdou a local irri- tation, mth indulo-euce in mastm'bation. INSISTENT AND DIPERATIVE CONCEPTS. Insistent and imperative concepts mark a species of mental weak- ness in which the xjatient's conduct is more or less strongly influenced^ he often being able to realize the domination of his affection. Some- times this realization is lost and the morbid impulses gain possession, so that in a condition of high tension he commits some act which is followed by subsequent repentance and distress. A number of names have been applied to forms of mental disease of this kind, and they extend from the lower form, which maybe called doubting insanity, or Gruhelsucht, to serious reasoning and impulsive insanity. The impulse which one feels when tempted to jump from a height, or to use some dangerous weapon that may be at hand, is an instance of an imperative concept of a low order. Certain insane acts may lead to the commission of others by patients of this kind with imitative tendencies, and this explains the eiji- demics of crime which occasionally occur whenever some j)articularh^ dramatic or "vWdely advertised horrible " sensation " has taken place. Under this head we find the crimes of instinctive ci'iminals whose dis- order is manifested in such as kleiDtomania, pyromania, and other im- pulsive forms of derangement, in which the dominant concept produces a physical impression, etc., which is manifested in the exercise of ex- plosive motor acti\dty, the offense against society possibly being the cidmination of months or j^ears of temptation and resistance, and pre- ceding well-developed and conspicuous insanity which has j)assed the bounds of inhibition. The dominance of the concept is rather constant, and is governed l)y the patient's surroundings and occupation. To the same extent its influ- ence maj'- be antagonized b}^ persistent exercise of will-power, by diver- sion and change in the mode of life. Intense concentration in one direction is ax)t to lead to the morbid exercise of activity and a frequent irritation and limited stimulation of ideational centers. The imperative concept may arise suddenly and without relation to the particular line of thought, being displayed in some erratic liehavior. Where it exists there is nearly always inlK^ited weakness, and often a remote history of alcoholism or epilej)sy. The hysterical w(nnan is more subject to this IXSJ^^ITY IN ITS MEDICO-LEGAL BEAliiyOS. 45 foi'iii of mcMital disorder than tlic male, as slie is in many ways more snbject to ideational activity than the latter. There may be a (^onditioii whieli is almost aiitomatie, the vxn\vA'\)i Ix'in*^' repeated over and over, and (^uite beyond the control of other inlii])itory or restraining influences. So far as its connection with special forms of disease is concerned, we iind that it is present, as a rule, in the depressed forms of insanity, as well as insanities with limited delusions, paranoia being an instance. Cases of suicidal and homicidal insanity, where the act is the result of so-called morbid impulse, are explained by the presence of dominant imperative concepts. Like delusions, these persistent concepts are often concealed by the patient, who surprises her friends or the community by some unlooked-for act ; and my note-books contain numerous observa- tions where people have thrown themselves from windows, or attempted suicide in one way or another, not having displayed beforehand any con- spicuous failure of mental health. Very often the explosion or giving way is followed by a reaction and a subsidence in the patient's insanity, at least for a time. Persistent concepts are likely to lead to the forma- tion of delusions, especially when no moral treatment is suggested. It may be stated that many of the cases of so-called moral insanity are, after all, nothing but a disorder characterized by imperative and insist- ent concepts. A number of terms have been applied by writers to the above-men- tioned forms of mental degeneration, where the conduct of the patient was determined by the existence of one kind of dominating concept and the more familiar forms of doubting insanity. These consist in the fear of open spaces — agoraphobia ; fear of the stars ; claustrophobia ; fear of contamination; imperative impulse to count, to touch, etc. An illustra- tive case of much interest may be presented : The patient was a man of thirty-five, presenting the stigmata of defective evolution. He was markedly dolichocephalic, his teeth were irregular, his forehead retreating, and his muscular motility impaii-ed. His family history was essentially neurotic. His mother, after a life passed as an extreme fanatic, ended her daj^s in a lunatic as^ylum. His father drank immoderately and died in an asjdum. One of his brothers was intemperate, and his sister was hysteric and neurasthenic, while one of his maternal uncles was also a drunkard. He had for several years been a prominent figure in the town in which he lived, and had devoted himself to prohibition, his enthusiasm being expressed in constant litiga- tion and self-glorification. His entire life had been modeled upon plans laid down by social reformers whose teachings were bad, and marriage guides and books upon domestic medicine played a great part in shaping his home life. In spite of his peculiarities he is a successful business man, and has saved enough to live in comfort without helping liis brothers, who are his partners, in the management of their business. His manner at the time of his visit was very hesitating and full of inde- cision. There was much hesitation in telling his story, and in answei'ing my questions he repeated himself frequently. He fully appreciated his mental state, and suffered very great agony of mind and want of faith in himself. His active mental unsoundness had lasted for several years, and began hy a gradual fear of defilement from contamination. It was rear sonable enough at first, and simply followed acts that naturally required subsequent resort to soap and water. But this increased so that he now 46 ^ SYSTEM OF LEGAL ALEDLCLXE. washes liis hands from tliii't^' to forty times daily, aud always does so after haudliug money. The impulses that eomjiel him to calculate are shown almost entirely in business matters, althougii his habit is now to weigh all coin that he receives or gives out, and this he has done for the past two years. The question of the honesty of others does not seem to figure lai-gely in this procedure, for he weighs the money which he gives to them and counts the l)ills repeatedly, often following the recipient several times in the day to know whether the amount he has paid is correct. He carries scales with him, not daiing to ti'ust himself without them, and while admitting the irksomeness of his bondage, suffers in- tensely if he forces himself to place them beyond Ms reach. In his efforts to escape the imperative impulse he often asks his brothers to take charge of his business, and he has finally been obliged to leave ever^i:hing in their hands. Some time ago his imperative concepts took another form, which consisted in the behef that ijaper, pieces of tin, scraps of h'on. on the sidewalk, street, or elsewhere, would do injury for which he would be morally, if not legally, responsible if he did not remove them. Paper upon the road that might frighten horses, scrap-tin that might wound them, loose cobljlestones, and other objects, he woidd constantly gather and imt out of harm's way. He was so dominated by his morbid fears and the possible consequences of neglect upon his part that he refused to sell nails to his customers without remo^T-Ug the splints, and if the nuts upon the bolts he sold were loose he would screw them up. He Avould question 2:)m'chasers as to the possible harm that might have occuiTed, and upon one occasion, when he went to Long Branch for his vacation, after an hour of anxiety and doubt upon the steamboat, he turned back at Sandy Hook, to remove a banana-skin he had passed without picking up on the sidewalk in New York. His morbid fears were excited by any object which might do hann. matches, combustibles, and shai-p tools Ijeing included, and he was finally ol:>liged to seek new emplo^-ment, taking charge of the bill-collecting part of the business. There was not in his case, anything that might be regarded as a delu- sion. His relations with every one except the hquor-dealers were pleasant. He slept well, as a rule, and suffered from insomnia and disturl)ed diges- tion only when he undei-went a pecuharly distressing period of doubt. AFFECTIONS OF ]MEMORY. An impaii'ment of memory is an exceedingly common s^^nptom of mental disease. It may consist in feeble receptivity — a condition of which imphes something more than a failure of attention — which prevents the concept from retaining its place in the brain : or it is due to a convolu- tional condition where the mental impressions are light or fugacious ; or it may arise from an ej^ileptic cf^)ndition, with tempoi-ary abolition of con- sciousness : or in a gi-aver form it signals a species of involutional degen- eration which follows or attains the actual destiiiction of the cells of the cerebral cortex. It is the all-important s^miptom in dementia, and most of the disorderly expressions of that condition are directly traceable to mental disorrofession of male prostitution, soliciting upon the streets and in parks when they get the opportunity. Physically, 50 A SYSTEM OF LEGAL MEDICINE. many of tliese men whom I have examined present the stigmata of de- generative insanity, or else physically approach the female t^-pe, and hypo- and epispadia,s are common. The female pervert or Lesbian rarely differs from others of her sex, j'' " ^ '~^\ except that the active agent is- gross, wears mannish attu-e^ and cultivates masculine hab- its* Other perverts enjoy sexual pleasure only when themselves subjected to phys- ical pain and degTadation; others derive enjoyment solely from toi'turing the objects of theii- passion; while others- alone gain satisfaction in act- ual contact with fetiches such as women's shoes and other articles of wear. In maniar hysteria and other expansive forms of insanity with exag- gerated sexual acti\dty, self- control is in part or totally lost, and we are presented with the conditions of nymph- omania and satyriasis, as ap- plied to the female and male,, which lead the patients to in- dulge in reckless excesses, in- decent and shameless proposals, and conduct which is a complete de- parture from the normal state. A refined and high-bred woman \\i]l make advances to car-drivers, porters, or servants — black or white ; while the victim of satyriasis, who perhaps happens to be a clergyman or dignified banker, "will expose his person in public or court the notice of the police. False accusations of improper assault are common with these people, and often lead to unhappy lawsuits or criminal proceedings. The sexual excitement, it must be remembered, may be only a local prompting and have no intellectual participation, and each case should be investigated carefully, with a view to the recognition of the person's ordinary mode of life, pre'sdous behavior, etc. As a rule there are con- comitant sj^mptoms of insanity. The conversation of young women who suffer from hysterical insan- ity is quite apt to dii-ect attention to the mental failure. For a long time before easily recognizable expressions of disease are detected, the patient will constantly talk about subjects naturally avoided by girls. One of my patients, a young person of very pure mind, devoted most of her time during the early development of her insanity to catechising a mar- ried sister about copulation and pregnancy, and finally extended her in- quiries to the other female and male members of the household. In this * The reader is referred to Krafft-Ebing's Pfiyelinpafliia Sexnalis ; Taxtil's La Cor- ri(pUon Fin dc Sicde, and various French romances, among them Mademoiselle du Man- j)in or Mademoiselle Giraud -ma Femme. Fiu. l:i. -?>Iale Sexual IVrvcrt. IXSAmTY IX ITS MEDICO-LEGAL BEAllIXGS. 51 case, as others, the interest hi reho-ious affairs becomes abnormally in- creased, and may or not be accompanied with a sense of self-depreciation which eventnally deepens into a delusion that the "unpardona])le sin" has been committed. Religious excitement and sexual irritation are the fruits of camp-meeting-s, revivals, and occasions when emotional activity is generated in crowds. It is not difficult to find examples of this ei'e- thism among the African devotees who practicic the Assouia, the der- vishes, and in other times among the fingellants. The subject of so-called religious insanity is (pute apt to l)ecome morbid, introspective, seclud- ing herself, mortifying tlie tiesli ; then she becomes exalted, and has hallucinations and delusions of a semi-amorous or erotic nature, believ- ing herself to be the bride of Christ or the agency of the immaculate conception. Some diseases are manifested by exaggeration of sexual vigor, and this is marked in paretic dementia, in mania and excited forms of mental disorder. In estal)lished involutional disease there is a decay not only of the sexual appetite, but a shamelessness and a weakness of desire which, in senile dementia., manifests itself in indecent exposure, urination in public, indecent assaults upon children, and libidinous loquaciousness. Impaii'ed or suspended volition characterizes conditions which may vary from ordinary feebleness to those which denote an actual suspen- sion of consciousness. When in a state of hypnosis or partial mental inhibition the individual may be made to perform certain suggested acts, he meanwhile being the subject of trance. Attention is suspended and inactive, and he does not realize the nature of his act unless attention is artificially directed. How far the ego and automatic sense of control play a part in limiting the power of suggestion is a matter of question, yet it has been demonstrated that it is impossible to make an ordinarily virtuous person commit a crime. The several indefinite conditions of semi-consciousness which consti- tute somnambulism, sleep-drunkenness, and dreaming, all imply a partial inhibition of self-cognizance and ideation ; and the diminished exercise of volition is the result of some automatic process or outside stimulation of subcortical function. The insane are apt to display an atonic indis- position. This not only characterizes the apathetic and stuporous vari- eties of melancholia, but is a feature of quiet dementia. Fixed positions are adopted, muscular movement is slow and rarely made mtliout sug- gestion, immobility is the rule, and at times the muscular condition is one of a cataleptic character. There need not be the rigidity attended by annssthesia and loss of consciousness, characteristic of catalepsy pi-oper, but in connection with great intellectual torpor there is a disposition for the legs or arms to remain in whatever position they may be placed. Recurrent attacks of this condition charactei'ize a form of insanity known as hifafoiiia, in which a primary melancholia is followed by an excited delusional condition, mth verbigeration, secondary inaction, and muscular rigidity, and termination in dementia. The chronic insane are sometimes exceedingly indifferent to external irritations or influences, especially when a condition of dementia has been reached. This is due not only to the mental torpor, but to an actual ana?stliesia. Burns, the contact of irritating substances, or the bites of insects, provoke no impression and no attem]it at removal. This in- difference indicates a suspension or impairment of consciousness which 52 ^ SYSTEM OF LEGAL 2IEDICIXE. is usually of slow duration, and divorces the patient from tlie rest of tlie world. He is unable to weigh and separate liis concepts, or to estimate and regulate their importance or association. Thev cannot be volunta- rily summoned, and eventually it is impossible to coordinate internal im- pressions. Self is no longer recognized, and in the confusioual condition a double j)ersonality may perhaps de"\'elop. DEFINITION AND CLASSIFICATION. The disorganization which results in the inharmonious operation of mental function must be considered as a gradual and intricate distiu-b- ance of psychic coordination. The comparatively orderly balancing and expression of feehng and thought that belong to sanity suffer a change, in which the conduct of the individual indicates a departni-e from a pre- viously existing normal standard. His new beha^dor places him at once in antagonism to the conventions of the intelligent majority of Ms fellows. Sometimes he never reaches a point of ordinary mental integrity — ^he is the product of neui'otic stock, the degenerate representative of faulty reproduction. Under some circumstances he is the weak-minded one — is the inventor "with a bee in his bonnet'' — the '-ne'er-do-well'" — the "crank'" — the reformer who suggests gi'eat issues and when pos- sessed of misplaced power persecutes for trifles, always mingling with his work his own desu*e for notoriety. Should he pass thi'ough childhood possessing ordinaiy power, he may at puberty be subjected to the sti-ain of development and go under, falHng into the ranks of the inciu-ably insane. Others of poor fiber are eonfi-onted at subsequent life epochs which they do not jjass through safely, developing evolutional and in- volutional insanities. Some indi^-icbTals whose weakness takes the form of moi'al degeneration may manifest such slight uitellectual aberration, and be so much like ordinary depra-\'ed j^eople, as to bring them within the pale of the law, which is at times indisposed to make allowance for then.' doubtful indications of insanity. To this class belong the matfoids described by Lombroso, whose unbalancing is a mixtiu'e of cleverness and duUness, and these are the eccentrics, in whom the gap between sanit}' and insanitj" is a mere crack. Insanity is then usually a profound alteration : certainly it is not. as we are sometimes induced to believe, a condition that may originate in a day or two, exist for a few hours, and disappear as quickly, although occasionally an explosion which means a lapse of responsibihty for a short time may occur in the course of an imperfectly recognized psychosis, which laymen are apt to disregard. DEFIXITIOX. It is an exceedingly difficult matter to give a perfectly satisfactory definition of insanity, or one that will meet the requirements of the law. In another place this matter will he gone into : it is sufficient here for me to point out the radical difference between the views entertained by the doctor and lawyer as to what constitutes mental aberration, though a common ground is being gradually attained. The latter has hitherto lieen guided by the hard decisions of another day, when a lunatic was INSANITY IN ITS MEDICO-LEGAL BEARINGS. 53 considered as "a wild animal/' and only exensed for the commission of crime when he knew the abstract difference between riii'ht and wrong. His standard of civil responsibility was only a slight grade higher. In a recent English ease {Rftoms grew worse and insomnia could not lie overcome by ordinary means he was sent to an asylum, where his condition did not mend. He still mani- fested a fear that he might do something to shock the ^Umighty. and 64 ^ SYSTEM OF LEGAL MEDICINE. absolutely refused to sit down. He stood so constantly that his feet and ankles became oedematous and he grew more and more weak, as coupled vrith this was a refusal to take food. It was fina% found nec- essary to strap him in bed, but despite artificial feeding and enforced rest he faded and died in collapse. Auditory hallucinations are indications of a more grave form of in- sanity than visual, and the same is true of sensory and olf active. In verbigeration or confused speech, the compounding of words attests an involved dissolution. Many forms of chi'onic insanity are characterized by periods of remission. Recm-rent insanity, or folk circidaire, is one of such. In the intervals the patients are apparently so much themselves that they are treated as sane persons. Paretic dementia, or general par- alysis, is another affection in which such an apparent return to sanity is found. Changes in the organic structures of course point to an unfavorable course and ending. This is true of the destruction of the cortex which belongs to paretic dementia, a disease of remarkably rapid progress. "With extreme exhaustion due to a continued Hght gTade of excitement we are apt to have an oedema of the brain, with collapse. Tliis is par- ticularly time of auEemic cases. The prognosis of insanities due to epilepsy, meningitis, sunstroke, injury, and syphihs is bad; and when lesions exist and produce progi-essive paralysis, convulsions, obstinate disorders of motihty or ocular disease, we can never take a favorable view of the patient's condition. The progressive appearance of symptoms in childhood or advanced age is bad. In the latter case an early fatal termination is to be feared,, as the powers of resistance are feeble. The insanities of childhood are usually due to hereditary influences ; and though the psychoses of pid^erty when acquii'ed are favorable, the reverse is true where the insane dia- thesis exists. It is held that " there is a difference, as regards prognosis^ between hereditary psychoses wliose outbreak is due to late accidental causes, and those in which heredity has produced a morbid development of character in early childhood. If the patient with hereditary taint has been mentally normal until his attack of insanity, the prognosis of the single attack is more favorable than in non-hereditary cases, but there is a gi-eater predisposition to relapses." (Kii-chhoff.) The following table is presented, which is based upon the oliservations of Krafft-Ebing, Schiile, Spitzka, Ku-chhoff, Clouston, Blandford, Savage^ Stearns, and my own experience, which indicates the gravity of symp- toms alone or associated : Uufavordble Indications. Favorable or not absolutely Bad Indications^. States characterized by slowly developing Rapidly developing tmconseiousness, ex- loss of consciousness, indifference, or cept in repeated attacks like epilepsy, hebetude, with staring. Loss of facial expression ; organic flatten- Retui'n of harmonious play of facial mus- ing or change in shape of featui'es. cles ; quick reflexes of emotional states. Moral indifference; degeneration shown Self-defilement in puerperal condition or by impulsive criminal or destructive acute mania not necessarily bad ; incon- acts, including filthy practices, self- tinence ta acute conditions compatible defilement ; protracted indifference, with with recovery, involuntary discharges of contents of bladder anil rectum. Protracted sexual excitement; manifest- IXSJXITF IX ITS MKDlCO-LEdAL JIEAUIXC.S. G.3 Unfavorable Indications. ation of sexual excitement or perver- sion in extreme youth or old age. Tjoss of sleep, with exhaustion. Motiveless acts subsequently justified by patient. Imperative concepts of long duration and their results. Periodical attacks. ^Uontinued depression and absorption, with picking of fingers and mucous membrane. Limited delusions constantly expressed. Tendency to homicide or suicide, with continued depression. Auditory hallucinations. Unequal contraction or minute symmet- rical contraction of pupils. Verbigeration. Chronic alcoholism or coarse cerebral dis- ease. Oongeuital or other stigmata. dutaneous anaesthesia ; tremor, with paralysis ; ocular symptoms ; optic neuritis ; absent or greatly increased tendinous reflexes. Catalepsy, with verbigeration. •Constant drooling of saliva, with charac- teristic posture. Involuntary discharges as result of indif- erence, as in dementia. Favorable or not ahsoluielij Had Indications. Increase of weight, with coiTe.sponding mental broadening. Unconscious acts of violence in acute mania as result of transient delusion. Rapidly developing mania, with sudden changes to depression. Simple depression, without fixation of ideas ; excitement ; irregularity. Confusional insanity. Visual hallucinations. An existing bodily condition such as anae- mia or a febrile disease to account for the mental change. Dilatation of pupils. Temporary causes, such as the influences of pregnancy and the puerperal state. Paroxysmal hysterical attacks ; hyperfes- thesia, with increased reflexes. Catalepsy, with simple or apathetic melancholia. Spitting as result of delusion. Involuntary discharges due to indiffer- ence, as in mania. Excitable forms of disease are more hopeful than those in which de- pression predominates, and Avhile an attack of acute mania may recover in two or tliree months, one of decided melancholia is at best apt to drag on for a much longer time, or actually end in dementia. Alcoholic and toxic insanities are recoverable unless the organic changes are profound or there is a transmitted inherent weakness. The Morbid Anatomy of Insanity. In all cases the configuration of the brain, its size, and the depth of the gray cortical substance, as well as the signs of recent disease, must be considered. If a small brain has an increased specific gravity which is disproportionate with its size, we shall probably detect the existence of sclerosis and atrophy. It has been found that the weight of this organ undergoes decided modifications in connection with insanity, and Clap- ham {^Yest Riding Reports, vol. \\., p. 11) presents a table which includes twelve nnndred cases of insanity. It would appear, according to this, that the brain-weight is greater in the insane, between the ages of forty .and fifty in women and between fifty and sixty in men, than at any other 66 A SYSTEM OF LEGAL MEDICIXE.. time ; that in the male the brain weighs more proportionate!}^ in idiocT than it does in the female ; that its average weight is greater in mania than melancholia, and in other forms of acnte insanity than in senile or organic dementia, imbecility, or paretic dementia. Grammes. n- m„-,^»,j.„7^,. Cerebellum, Pons, .„„ Disease. Encephalon. and Medulla. ^^^■ Idiocy 1148.947 156.7 21.94 Imbecility 1285.009 174.6 36.2 Dementia (simple) 1310.956 169.7 49.132 Seuile 1278.382 163.8 64.843 Organic 1291.949 170.5 53.810 Mania, melancholia, and acute forms . 1350.425 172.8 42.082 General paralysis 1270.271 174.0 41.610 Epileptic insanity 1314.410 164.4 36.646 Chronic mania 1327.267 171.9 46.863 Brain wasting 1256.644 164.3 60.929 We are enabled to detect the depth of the gray matter of the con- volutions by means of an instrument invented by Dr. Herbert Major. This consists of a glass tube, finely gi-aduated, by which portions of the cortex of the brain may be removed by thrusting the gauge into the particular convolution the depth of which it is desired to determine, and remo^dng a plug of white and gray matter. It will be found that the depth of the gray matter in certain forms of insanity has undei-gone material diminution ; and in those where congenital deficiency is sus- pected we shall find that the proportion of the white and gray substances is very much changed, the latter being reduced. In measming the depth of the gray substance of the convolutions it will be found that it is- reduced from eight one-liundi^edths of an inch to six or seven one-hnn- di'edths. Bucknill and Tuke prefer measurements made with a hair- divider, a variet}^ of small compass, to the instriiment invented by Herbert Major. Benedikt and other German waiters place great reliance upon pecul- iarities in the arrangements of the convolutions and sulci in the brains of insane criminals. While I do not beheve that Benedikt's ideas are always susceptil)le of proof so far as it is possible to definitely connect gyral and fissural anomalies with specific forms of moral depaiture, it is still a noteworthy fact that in the cerebrum of the congenital criminal there is great complexity and irregularity in the arrangemeut of the con- volutional folds and fissures. In his book upon the subject he presents- a number of autopsies the subjects of which were criminals, and in every instance there were certain peculiarities which he has minutely detailed,, and these consisted not only in the excessive fissure development, but in the repeated existence of asymmetries of the brain and the skull itself. The parietal lobe was usually dwarfed, the cerebellum was only partially covered by the occipital lobe, and there was a deficiency in Wernicke's fissure ; the interparietal fissure communicated very frequently with the fissures of Sylvius, and the parieto-occipital with the horizontal and inter- parietal. Asymmetry of the two hemispheres and convolutional errors of development should always be noted. The brain in imbeciles and idiots presents malformations and arrest- ment of development Avhicli ai'e quite characteristic. These modifications JXSAXITl' IX ITS MEDICO-LEGAL BEARINGS. 67 take the form of atropliios of parts or gi-oups of convolutions of the cortex ; and the partial atrophies are revealed by a thinning of the folds, and hy a eorrespondiug- enliirgement and deptli of certain fissures. These are prinei2)ally in the frontal convolutions, which present irreg-ularities of formation. Asynnnetry is very noticeable in the brains of idiots, the two lobes often showing a want of correspondence which is decided, as well as a poverty in the num- ber and depth of the sulci ; and (ionvolutional flattening. Such brains are often exceedingly small and unformed. That pre- sented by Ireland is a good ex- ample (Fig. 13) of imperfect de- velopment. From a pathological point of view we find arrested development depending upon de- fects in the apparatus of nour- ishment in the cortical sub- stance. Luys {Traife CJinique et Fra- tique des Maladies 2[entales, 1881) has devoted much attention to the subject of the convolutional anatomy of the brain in the in- sane. He finds that the fissure of Sylvius is usually enlarged, and extends much farther back than it does in the normal brain, exposing the insula ; while the fissure of Eolando is nearly normal, but its continuity is interrupted by ii-regularities which jut out from the marginal convolutions. This writer has collected pathological data of great interest, showing that certain definite convolutional changes are to be found in many cases of insanity. According to him, the most frequent are those seen in the frontal convolutions, which are much more irregularly disposed in the right than in the left hemisphere. The first frontal, especially, is xqyy frequently atrophied and diminished in breadth. Luys has found in a case with well-marked hallucinations that in the internal aspect of one cerebral hemisphere the paracentral lol)ule was prominent, the first frontal depressed, and the second frontal had undergone at its anterior part de- cided changes. Here its continuity w^as broken up by a series of second- aiy multiple folds having a vermiform appearance and bridges over the superior frontal fissure, which was obliterated. In certain cases of chronic dementia the second frontal convolution becomes almost rudi- mentary. The third frontal con^'olution (the speech center) is rarely modified, except when there is aphasia. Luys has found in tlu-ee deaf- mutes that it was atrophied upon the left side. The ascending frontal convolution often presents a change in its length and continuity. At its union Avith the second frontal we find nu- merous variations, and a change is seen at the origin of the third frontal. The ascending parietal is quite rarely alf ected, except in cases AA-ith para- ng. 13.— Brain of Microcephale (Ireland), showing the imflnished fissure occipitalis perpen- dicularis externa, the parallel fissure, the central fissure, which is incomplete, and the posterior branch of Sylvian fissure, a. The superior frontal gyrus; /j, the inferior frontal gyrus; d, anterior central gyrus ; f/', posterior central gyrus ; c, pras- cuneus; /, lobulus supra marginalis; f/, gyrus angularis; i", cuneus; p, gyrus temporalis supe- rior; o, gyrus temporalis medius. 68 ^ SYSTEM OF LEGAL MEDICINE. lytic sjTnptoms. The angular g^Tus is sometimes affected Avlien there are auditory halluciuatious. The paracentral lobule is often the seat of pathological changes, on one side or both, and in advanced cases of dementia both sides will be affected. In the insane it will be found, especially in forms of chi-onic mania, or where there has been excitement, that the meninges are thickened, liyjiertemic, or that there are heematoma?. The dura mater is often ad- herent to the skull, and the other membranes show e\adences of various grades of inflammation, so that it is difficult to remove the arachnoid and pia mater without tearing away more or less of the brain sub- stance. Lesions of the blood-vessels may be found which vary from simple congestion to atheromatous degeneration or permanent dilata- tion, and these are either in the substance of the meninges or in the brain itself. The vascular condition of the brain substance is either one of hyper- semia or antemia. Evidences of hypertemia are common in disease at- tended with excitement, such as mania or dementia paralytica. The gray substance is darker and the white is more pink than in health. Minute extravasations or local tracts of active congestion are found. In general 2>aresis these spots of hypereemia have been found to be more marked in the frontal region, though in this disease it is common to find very gen- eral congestion. In melanchoha we meet with a pale condition of the tissues, with diminished caliber of vessels and perivasculai* accumulation of fluid, and the brain is blanched and soft. Territories of oedematous brain are found in association mth the plugging up of small vessels by an embolus, or as the result of thrombosis. There may be bony plates in the dura mater, wliich are very common in chronic insanity, or adven- titious substances scattered over the surface of the brain, both at the convexity and the base. The brain itself presents certain changes in the appearance of its convolutions and deeper parts which are quite con- spicuous, and softenmg and sclerosis, gi^dng rise to atrophy, depression, and changes of color. The lining-membrane of the ventricles is often thickened and the seat of a granular change ; and an accumulation of serous fluid, not only in these ca\dties but in the meshes of the arachnoid, both at the upper surface and at the base of the brain, is present. The substance of the brain may be the seat of a diffused change, there being small collections of indurated tissue, which are so frequently present in paretic dementia. In insanity produced by alcohol this appearance is particularly notice- able. In other cases we find collections of gummatous substance pecul- iar to syphilis. In still others, those with diseased vessels, there are one or more partially organized blood-clots, and perhaps some softening. In many brains we shall find a condition known as the etaf crible, wliich consists in a number of small openings giving to the brain a porous appearance, and it is a result of a previous hA"i:)era?mia from probable exudation of serum and atrophy. It is rare to find increase in size of the brain as an indication of chronic insanity — atrophy is much more common. Attention may be called to the thickening of the cranial bones in chronic insanity and the existence of bony spiculse. Greding presents 21G autopsies : 167 of these showed thickening, and 38 more or less thin- ness of the bones. IXSAXITY IX ITS MEDICO-LKGAL BEAUlXiiS. G9 111 mchnirJioUd Liiys has found in several eases ^veat liyperaBmia of the gray suljstanee of the third ventriele. The left optie thalamus pre- sented on its internal faee hyix'ra'inie redness, wliieh was also found in the third ventriele. The gray substanee of the eortex of one of these patients was thin, and most of the eonvolutions appeared of a pale color, with irregular vaseular arborizations irregularly disseminated. It seems to l^e a peculiarity of this form of disease that there is a general ischemia, with localized spots of liypeiu'inia. In some cases of profound inelanchoUa U'ith stupor the 1 train was found to l)e completely exsanguinated, tlie white sul)stance deprived of ^'essels, and an appearance of atrophy of the cortex and small vascular groups was presented {des petlts honquda vasculier dis- poser en ilofs). In cases of pari'tic deniputia excessive and abundant proliferation of the nem'oglia, with choking of the nerve cells, is apparent, the latter being diminished in number. The white substance as well as the gi'ay presents the same appearance of sclerosis ; the nerve fibers appear as withered filaments, and are torn and much reduced in size ; and there nre areohi? which indicate the disappearance of nervous elements. Ill aritte mania evidences of active and \nolent hyj^era^mia in all parts of the brain are found, but the vessels of the corpora striata are most dilated and engorged, and the white substance not as much injected as the gray. In one of Luy's cases there was yellow^ coloration of the insula, with degeneration of all the nerve elements of this region. In another, an old foyer of softening, occupying the center of the pons, was found, the w^alls of which were incrusted with coloring-matter, gTanular cor- puscles, and crystals of ha'matoidin, which indicated the existence of prolonged congestion, and which for some time had played the role in this region of a pathological point of irritation. The causation of meningeal inflammatiou by bacteria has recently been fixed to a certainty by several observers. In acute delirium Rasori {GeniraJhlatt fiir BalxterioJogie, etc., October 2, 1893, quoted by Potts) de- scribed a bacillus resembling the pneumonia coccus, and quite lately Potts {Philadflpliia Medical JS'eivs, Juue 30, 1894, p. 718) has rei^orted a most •carefully observed case which ended fatally. The temperature reached 108.2 just before death, which was preceded by a carbuncle, and later by acute delirium, insomnia, active delusions of persecution, and hallucina- tions of a lively nature w4iich were chiefl}' visual. The autopsy was made about seventeen hours after death. The brain and meninges appeared to be normal, as were all the other organs of the body. Some of the cere- bro-spiiial fluid that had drained into the base of the skull was collected in a small bottle previously sterilized with boiling w^ater, and from this ■cultures were made, with the result that the presence of a bacillus, an- swering to the description of the so-called Micrococcus lanceolatus or pneumonia coccus of Fraenkel and Weichselbaum, was demonstrated. The StaphijlococcKS pjyogenes aureus and the Staphylococcus pyoijenes alhus were also present.* The microscoi3ic appearances of diseased nervous tissue are perhaps * Microscopic examination of the cerebral cortex showed the appearances described by Osier, i.e., perivascular dilatatiou aud leucocj-tes in the h-mpli sheaths aud peri- gangliar spaces. 70 A SYSTEM OF LEGAL MEDICINE. of greater interest than any others, and in cases where no grave lesions are presented the microscope will often reveal deUcate changes, which consist most commonly in degeneration of the nerve cells of the cortex^ and vascular hyperaemia and its consequences. The large cells of the cortical gray substance often break down, and leave in then* places- collections of granular matter, which may be either found in isolated masses or the cell wall may be intact and its contents entu-ely disorgan- ized, there being disappearance of the nuclear elements. (Plate I.) We shall also find that the intercommunicating fibers and nerve-cell processes are broken off, and that the intercellular connective tissue is increased,, with proliferation of the nem-ogiia cells, and perhaps there may be the appearance of amyloid bodies. The blood-vessels are choked. There is exudation of coloring-matter and infiltration. In hypereemic states the- vessels are dilated, their Avails being covered by fat granules and h^ma- toidin crystals. Sometimes masses of pigment are found. The vessels are varicose or disrupted, and the perivascular spaces may be filled with exudation corpuscles. The nerve cells undergo notable changes in dis- ease. It has been found that in cases of insanity with hallucination they are greatly increased in size, and Meschede has found in paretic dementia that the increase is very decided. Luys, on the other hand, has found a reduction of the cells in paretic dementia, as well as a diminution in their number. In some brains we find small vacuoles, others than those due to congestion, scattered through the brain substance, which, however, are more often the result of careless manipulation than of a pathological process. In this connection a word of caution is necessary, for it is a very easy matter, through improper hardening or incautious staining, to so alter the arrangement and character of the anatomical elements as to produce appearances in every respect resembling those of actual disease. Hard- ening in alcohol is quite likely, unless great care be used, to have this result, and sometimes carmine-staining with a badly prepared solution will give granular changes which are very confusing. In hardening the brain, especially where medico-legal questions are involved, we must fre- quently change the fluid, protect it from dust, and conduct our manipu- lations in a systematic and careful manner ; and it is weU to have our observations confirmed by another person. Physical Signs of Insanity. The external evidences of existing mental disease are iisually more or less pronounced. The objective evidences in cases in which arrested brain development exists are varied and characteristic, consisting mainly in asymmetry of the head, the cranium, and face ; a misshapen frame, club-foot, a,s well as trophic defects of various kinds. These blights may- be recognized at an early age or do not develop until later. Clouston aptly says : " It is a truism that each age has its own lieauty ; it is equally true that each age has its own deformity. A beautiful child may become an unprepossessing youth, because, through hereditary influences, the development of the countenance, the form, and the movements has not PLATE I. i^ii?..i X 300 Fig. J X 650 ^Mifi'o.scoijic ai)pcai'aiue of brain of epileptic dement, sbovvinK cellular degeneration. (Cloiistou.) Fi^. 1.— c(. Nerve cell showing well-,stained nucleus, with small amount of protoplasm round it ; />, nerve cell showing remains of apex process and granules of pigment in pnjtoplasin : (\ mass of cell protoplasm without nucleus; r(, nucleus of nerve cell, apparently destitute of protoplasm ; r;, nucleus of neui-oglia cell. (X 300.) Fig. 2.—A nerve cell showing granular condition of protoplasm, collections of pigment granules, irregular staining of nuc'leus, and atrophy of protopla.sm and processes. (X 6.")0.) 71 72 INSANITY IN ITS MEDICO-LEGAL BEARINGS. 73 p^one on tlie lines tliat make for mature l)eauty. There has been a lack of harmonious progress; the bodily ideal of the age of adolescence has not been attained, through the working of an evil heredity. Some feat- ures have been retarded in growth, some distorted, some overgrown. It is beyond a doubt in families with neurotic hereditary taint that we find marked ugliness, asymmetry, dwarfishness, hunehljack, scjuint, un- gainly movements, hoarse laughing, lioljbledehoyism, uncomfortable limbs, and such like departures from the anatomical and physiological ideal." By far the most suggestive index of the insane temperament is the misshapen head. While a large number of insane persons have the long or dolklioceplialic head, such a cranial peculiarity has not the suggestive- uess of one of a rhomboidal type, or when the two sides are asymmetri- cal, but at best such appearances are only indices and not proofs of mental weakness. The teeth of imbeciles are uneven, the incisors being sometimes crenated; the ears are misshapen or irregular, contain the Darwinian tubercule, and are satyr-shaped or abnormally large or small. Hypermetropia is common. The finger-ends are expanded and the move- ments of the body indolent. The appearance and conduct of an insane person of course depend very much upon his form of disease, as well as its stage and duration. It is always possible to witness a radical and progressive alteration in cases that have become chronic, a physical change keeping pace with the niBntal deterioration. Women who have been comely become ugly. E i^ression alters, the lines of the forehead and lower part of the face b( eoming deepened, and the dominant affective feeling leaving its im- p] ess. The facial furrows that form are referred to by many as im- p rtant diagnostic nuirks in chronic insanity, especially the depressed C( nditions such as hypochondriacal insanity and melancholia. In the latter there may be a distinct transverse furrow, which sometimes extends across the entire forehead or is again unilateral, appear- ing over one eye. Through contraction of the frontal muscles, the corrugator su- percilii, horizontal folds of the forehead and deep ver- tical folds extending up- ward from the root of the nose are produced. (Fig. 14. ) As a result of the persistent and constant contraction of other muscles, we find droop- ing of the lower lip and re- laxation of the nmscles at the side of the face. In mania and other elated con- ditions there are no constant traces left except in chronic states, but the muscles being in lively play the experience is one of pleasure and jo,y, or anger and excitenumt. Through trophic changes and muscular atony we find that the features 74 A SYSTEM OF LEGAL MEDICIXE. lose tlieir cliaraeter, the furrows disappearing, and the mouth becoming- changed in mobility. Blankness eventually comes, with mental vacuity. (Fig. 15.) Tlie attitude, gestures, locomotion, all undergo changes, and the speech is hesitating, ex- plosive, and embarrassed, or the subject indulges in ve)i)ige)'afio)i, which consists in the repetition of words in an irrelevant way, so that the resultant effect is a ro- domontade of a meaningless kind. New words are coined, and syllables joined incon- gruousl}', so that the result is a compound creation which usually conveys a liombastic hint of the pa- tient's grandiose delusions. The formation of new^ words Fig. 15. is often the result of hallu- cination or delusion. In the first case the distorted percepts and absurd concepts which usually spring from auditory hallucinations lead the patient to put into words the things he imagines he hears. The words used are often most distorted and con- fused, and not only consist of those of his own language, but combined words made by the conjunction of syllables from some foreign word with one of Ms own tongue. There is in excited and confused patients a ten- dency to indulge in phrases that have a mj^stic significance. Sometimes a repeated distortion of a syllable wiU be persisted in. One of my patients in a conversation of a few minutes used the word "came" for "come," "becase" for "because," etc., at least a dozen times. EcliolaJia is a term apphed to the form of speech in Avhich the last syllable of words heard or the last word articulated by the patient himself is repeated. The letters of the patient ordinarily convey the best idea of his con- fusion, even when he is on his guard in other ways, and I append the production of an insane subject, which illustrates a form of phrase repe- tition and extravagance of fantastic w^ord use which cln-onic patients so often indulge in. This paranoiac patient thus describes a flag she has designed : CHURCH SUNDAY SCHOOL AND STATE BANNER OF THE UNITED STATES OP MINNEHAHA AND COLUMBIA. Ordinarily quite Large White Silk for the wliole of the background of Church Banner and a tinge off into blue as dark as jjerfect taste would allow for State Banner of United States of Minnehaha and Columbia including Mary Fidelia Bourne Stellar or Planetary Universe. State Flag of the United States near the top with either the full number of States and Territories or tlie Original Thirteen Meaning twelve originally ours and one gi'eat Cruelty M'e adopt to protect in full natural color with Abraham Lincoln holding under- neath the Motto Malice toward none Cliarity for all. And tlie Holy Dove above. Be- low on the Eight Side an Orange Tree in full Bloom and delicate fruit in natural color with Justice written upon it. In the center lower than tojj of Orange tree a group of figures in whatever color perfect taste orders an American or Hebrew Cross with Lilies of the Valley and ordinary Espiritu Santo twining over it and perliaps grape IXSANITY ly ITS MEDICO-LEGAL BEARINGS. 75 vine and by me hold by me as Goddess of Liberty and America Benevolence and Truth ■written upon it at lier feet comin<,' up perhaps as far a« the knees agi-icultiiral instru- ment with grapes in bloom or fruit over it on each side two well-known ^Monarch with ■weapons of defusive warfare and work One and Aiistaradat as Peter Bowne the Groat of Russia who no menial service honestly and noble peii'ormer wrong for the highest dignity to do he over the right with a well known face Then on the left of Goddess of Liberty and America Charles the 5tli of Twelth of Spain Conqueror of the Netherlands Prescott has a memoir highly interesting of him a Thorough penitent with a well known face and ten Coranumdents in tablet form in Instrument of Agriculture with Laborore et Ovare and Return for Evil together Underneath Orange and Peach tree, z, number of Irregular Lumps of Dirt and Stone with Tiger Lily very beautifid and Dandelions and jealousy grass at the bottonr over Lumj) of Dirt t^vo skeltons Hands with know number of Stoned unjustly in America or its Representation to please Cruelty who were Cosmopolitans Aristocrats chiefly from British India and knowing heathendom practically many did not wish to be redeem back to it nor to mention Jesus name after as it brought a bad fate or to know the private affairs of Gods or Goddess and wished to be impartial for that reason were probably starved by the cruel Creation a number of Friends of Goddess of Liberty or America being among the num- ber several private friends all her political ones who loved to hear the Truth as the Spirit of Truth of Truth Through Catholic Aposlitic or Methodist Episcopal declared it. In its purity and truth. On the lefthand side of group as high as Orange a Missippi Peach in full bloom and delicate fruit natural Color on it Mercy written. Written in Lumps of Dirt and Stone Cruelty Selfishness Wrong Ingratitude False- hood Treachery Kindness in prosperity, unkindness in adversity or False Friendliness. Meanness Uncleanness Lust or Cruelty Selfishness Ingratitude TjTanny Error False- hood Treachery Kindness in prosperity unkindness in adversity Uncleanness Lust. At the bottom imderneath Jealousy grass and dandelion the Words Faith Hoj)e and Charity on State Banner with perhaps the passage of Scripture. As I live south the Lord God I have no pleasure in the Death of the Wicked but rather that He may turn from his wickedness and live tm'n ye turn ye for why will ye die. D f^JHSyO K^^^JU\kIJJ^xO iJbijf hur-l--^^ /AA-./0-S^XAA-/o^^,^ juA^ M-^^-yiy-xjJ ^ Fig. 16. — Writing of a paranoiac. The handwriting itself underg-oes a decided change in character, aud is often feeble and uncertain or else suggests an exaggerated vigor aud nervous force resulting in the production of bizarre scrolls, markings, aud interlineations. (Fig. 16.) Of coui'se the disposition to write varies ■with 76 ^ SYSTEM OF LEGAL MEDICINE. the diseased mental activity, those who are atonic or demented, writing but little, while the victim of chronic mania has a veritable cacoatlies scri- dendi. This is especially the case in paranoia, the person of one idea filling pages with diagrams, sketches, and sjanbolic references, often of a mathe- matical or religions character. One of the best cases of this kind is that of a Mr. B., an artist, sent by me to Bloomingdale, where his extraordi- nary ideas found expression in exquisitely executed illustrations which have been collected and published by Dr. Noyes. /tT^C^-i^ yy'€».^€^cL ^^«&. /55»^ tf^^ ^<^y^ tM^^--€!ia.i^u^ Gf.^^ J^i^ "^z^^^z^^^ Fig. 17. — Writing of an educated paretic dement; advanced stage. In paralytic dementia and other insanities where there is mental weak- ness and lack of attention, it is common to find words omitted or unfin- ished, as well as tremor and irregularity ; and specimens taken at different times, when compared, show the degeneration very beautifully. (Figs. 17 and 18.) The attitude of the lunatic is as a rule largely determined by the nature of his hallucinations, should thej^ be present, and he changes liis position and behaves in a measure as he would if the impressions he re- ceived were real. Should he be the suljject of one of the exalted kinds of mental disease, he shows it by his excited manner, flushed face, bright eyes, quick play of features, bristly hair, quick speech, and restlessness ; while the reverse is true of atonic melancholia, where inaction character- izes the condition. The patient is listless, taciturn, absorbed, and will not usually move unless stimulated and urged. When anxiety is a feat- ure we are presented Avith the expression we would find in a normal condition, only intensified. r ^Z^^yzA^^ / Fig. 18. Writing sliowing deterioration in paretic dementia. (Bacon.) o, b, Writing of educated man, with interval of several months; c, (7, writing of nnedu- cated man with commencing paretic dementia, c being written soon after admission to asy- lum, and d his writing in health. 78 A SYSTEM OF LEGAL MEDICINE. Tlie existence of delusions is often reflected in dress, and in asylums one or two patients are iisually shown wlio decorate themselves with all the bits of bright metal and gay colors they can find. This kind of adornment is usually associated Avith unsj^stematized delusions of power, the patient believing himself to be a potentate. The Ear. — Attention has been called to the misshapen ear, which is likely to be an index of a prolonged degenerate condition. There is an- other deformity of the ear belonging to chronic insanity, and this con- sists in a striking deformity due at first to impaired function of the sympathetic fibers and a low condition of vitality of the organ, and to subsequent injury and inflammation and ultimate contraction, so that there is a residtant change in shape and size which is conspicuous. While the ear is congested, as is often the case in chi'onic insanity, it is liable to be injured or bruised, and laceration of small blood-vessels oc- curs, followed by extravasation. The condition is known as othcematoma, or the "insane ear." Othfematoma may be associated with nearlj^- every form of chronic insanity, and is usually of --- --<^- grave omen so far as complete recovery is concerned. (Fig. 19.) Through constant pull- ing or tugging upon the part of the patient, even though the above condition may not exist, the ear often undergoes a distortion. TJie Eye. — The pupils constantly present changes or inequalities that are suggestive and valuable in verifying other indications of disease of the brain. In organic insani- ties, especially paretic dementia, there is at times iinequal dilatation, or symmetrical con- traction or dilatation. In paretic dementia there is often pupilary action with accom- modation but not with light stimulation. In mania they are usually contracted, in melan- cholia of all forms dilated. The dilated, mobile pupil of the epileptic is present in about halt the cases. In insanities due to coarse brain disease, or in alcoholic insanity, it is not unusual to find paralysis of the motor apparatus of the eye, as well as atrophy and disease of the fundus oculi. The muscular condition of the insane is sometimes significant, especially when the disturbances of motility consist in fine tremors, which indicate a lowered muscular tone. These may best be witnessed in the muscles of the face, tongue, and hands in paretic dementia. Convulsions, ataxia, and certain automatic movements are prominent diagnostic signs of cer- tain insanities mth distinct organic causation, such as the sj^hilitic and alcoholic psychoses. The tendinous reflexes are as a rule increased in insanities where mental inhibition is suspended, and in such degener- ative affections as paretic dementia they are more active, or, on the con- trary, absolutely gone. Cutaneous AncBsthesia. — Lowered cutaneous sensibility is highly char- acteristic of stupid or demented states, or forms the basis of delusions and hallucinations in the manner elsewhere described. It is undoubt- edly due at times to autohypnotism, which is associated mth those qui- Fig. 19. ixsjy/ry ix jt.s mjjdico-ijjgal lUJ.iL'iya.'^. 7'r()vv taller than a boy of eight yeai-s. (Broca.) IMany always remain nndevelopt'd, others are taught to talk, and l)ut few ad- vance beyond the mental status of a child of two years. The antero- posterior dianu^ter of the skidl may be no more than over 10 to 13 centi- meters, the horizontal cir(nimference may bo from 32 to 37 centimeters, and the capacity is alwa3^s below GOO, and may be no more than 300 <3ubic centimeters. The case of the microcephale John Rouse is one well known in psychiatrical literature. He was under my care for several years, and as a microcephale ranks with the eases reported by Ireland. •John Rouse is a))out fifty, weighs 72 pounds, is 4 feet 7^ inches high. The circumference of the head, taken at a j)oint one inch above the root of the nose anteriorly and the occipital protuberance posteriori}', is 15 inches. The biaural arc is 8 inches, and the anteroposterior arc is 8 inches. These measurements must be reduced about an inch hy reason of the existence of thick, coarse hair. His teeth have disappeared, and he has a double cataract. The left ear is the seat of a hematoma. His intellect is almost nil. He can only say a few words, without any idea of their meaning. Broca also describes the demi-microeephale. Very •often weak-minded children of this kind present no diminution in the size of their crania ; in fact, I think the majority of my own cases were the possessors of unusually large heads. The scapliocephalons deformity consists of an exaggeration of the vertical and longitudinal diameters ; the plagiocepliahus or obhque-oval deformity, depends upon premature obliteration of one of the branches of the coronal suture and of the lamb- doidal suture. In the jjlafijcephalous deformity the sinciput is flattened •and the vertical diameter is diminished ; in the acrocephalous head, on the contrary, the sinciput is conical and there is an increase in the ver- tical diameter. Indication of prematui*e closing of the sutures is often present, and .should be looked for. The height of the palatal arch has been referred to, and an increase with basal narrowing is regarded by most authors as .an invariable sign of defective development. I present an excellent plate of Clouston, which enables the reader to compare several t}T3es of mouth-roof — the normal, the neurotic, and the deformed. The mouth of the idiot is large, and the lips coarse and full ; the teeth are une\'en or in a double row, and perhaps connected with fissin-ing of the hard palate ; harelip, or that projection of the lower jaw known as progiiafJiisni, may be present, and when it is, is highly characteristic. The features of the idiot are coarse. His vision is defective or he may be actually l)Iind, or he is apt to suffer from disease not only of the eyeball itself, but its muscles as well, so that there may be atrophy of the disk, cataract, or strabismus, and there is an inability to fix the e3^e upon small objects. The hair upon the body is sometimes coarse and plentiful, or, on the other hand, is unusually fine and silky, though this latter condition of affairs is, I think, more marked in imbecility. Idiots are slow and awk- ward in their movements, disinclined to Avork, as the niuscular SA'stem is weak. Cutaneous sensibility may be either elevated or depressed ; in the latter case there is a remarkable t(^leranee of external disagrei-able irritation. Sometimes there is loss of smell. The gait is often waddling and unsteady, and the grasp weak. His habits are untidy and dis- gusting; he gorges himself with whatever may be placed before him, A SYSTEM OF LEGAL MEDICINE. SECTIONS OF STANDARD PALATES. TY PICA Li NEUROTIC. DEFORMED TRANSVERSE, LONGITUDINAL. The Soft Palate Is represented by & dotted line* Fig. 20.— Casts of vault of mouth showing defects in hard palate. (Clouston.>' 7. TYPICAL. 3. DEFORMED, 2?^-v 4. NEUROTIC. 5. DEFORMED. 6. DEFORMED with Central Ridge> EXTREMELY DEFORMED PALATES. Fig. 21. Casts of palates, showing standard types on left, and changes found in adolescent insanity on right. (Clouston.) 83 84 A SYSTEM OF LEGAL MEDICINE. and often carries, for lioiu'S at a time, in liis mouth a Ijolns of food. He- voids his urine and faeces wherever he maj^ be, and veiy often indulges in mastm-bation and objectionable amusements of a "vile character. The idiot is either non compos, or his capacity is, as Pinel has observed^ below that of another jjerson of his own age. In some cases the intelli- gence is even upon a par with that of some of the lower animals, and mental expression is chiefly emotional. He manifests feeble degrees of pleasiu-e when shown bright objects, and indulges in fitful and short- lived gusts of passion without cause. He delights in rhythmical, musical sounds, or to indulge in automatic movements. His instincts are animal ; and without the restraint of judgment he gratifies ever}^ appetite, how- ever low. In completely idiotic persons there is no sign of recognition,, no indication of memoiy, and the intellectual capacity is rudimentary. There is the absence of the piimary mental apparatus, the absence prob- ably of a sufficient number of sensory cells and their connecting fila- ments, and the result is the absence of mind. The general conspicu- ous mental weakness of an idiot is the lost power of attention, and this accounts for most of the pecuharities. Xothing impresses him ; percep- tion is dulled, concepts are weak, and emotions are not, therefore, legiti- mately aroused. The basis of mental expression is the bodily or instinc- tive feeling : the senses of hunger, pain, satiety, comfort, and the like^ influence the conduct, and liis outward manifestations are of a feeble nature and bear a close connection \nth the condition of the ego. The- expressed feehng is unbalanced, inhannonious, and is often evoked by unexpected or ordinarily ineffective stimuli. The speech of idiotic children has alwa\^s been considered an inter- esting index of the mental failui'e. Its connection with the disorderly complexity of organized ideas, and the manifestations of its forms of impairment, perhaps point as fully as any other sjTnptom to the degen- eracy. The defects of speech vary fi-om absolute mutism to a state of apparent, though feeble, development, where perhaps a free flow of words exists, without systematized mental creation or reg-ulation. Many vaga- ries are found. Sometunes the vocabulary is very limited, being con- fined to a dozen or more words which the child invariably uses for the expression oX its simple wishes. Hun reported a case of this kind, and Clouston another. In the case of the latter, ten words served to des- ignate her nui'se, her own name, those of various animals and objects, as well as to convey infonnation as to her needs. Such examiDles are common enough, and the simple words are curious, and frequently have no phonetic connection "v\ith any particular object. The range is rarely extended, though occasionally skillful teaching may result in the use of new and api:)licable exx^ressions. The speech-defect is sometimes a gen- uine aphasia, and is associated with hemiplegia and epilepsy. Other children suljstitute consonants, using T for K, D for Gr, D for Z, etc. Echolalia, sfammerinf/, screamirifj, the utterance of rhythmical and monoto- nous sounds, the mimicry of the noises and cries of animals, are all morbid expressions. There are many beautiful childi-en who come into the world "oith an utter arrest of cerebral development, whose beautiful and expressive faces are strangely at variance with the paucity of mind. Clouston, in detaihug a case where there was an hereditary arrest of development of the mental cortex alone, the trophic, motor, and sensory centers acting- ix.'ijyiTy jx it:s medico-legal leaiuxgs. 85 normally, while there was no emotion, reasoning power, no power of attention or speeeh, yet "an exeeptionally sweet faee, fine, expressive eyes, wonderfully good walking, and a well-formed body,'' says : " The face and eye of such an idiot tell lies when they thus express mind." The sexual organs of these sulgects are sometimes the seat of mal- formations, and mon()r(;liidism, hermaphrodism, and atypical errors are disclosed upon inspection. Their sexual appetite is perverted, and when any desire exists, which is not often the case, the adult idiot is apt to commit violent assaults upon women and children. Although copulation is possible, fertilization does not, I believe, occur, although it is so claimed by some. The idiot, strange to say, is usually susceptible to more direct and prompt development from training than the imljecile, for in the former there is often no actual destruction of nervous matter, but rather a dor- mant condition that can be much improved by education — by an approach from without, that is to say, through an appeal to the senses primai'ily, and a removal, if possible, of the inhibition of speech. Teaching should be directed to symbol formation and association. Cretinism is a form of idiocy attended by a degeneration of the thy- roid glands, owing its origin to endemic influences. It is common in southern Eiu'ope, especially in the Pyrenees, and seems to be rather a disease of high altitudes than elsewhere. The physical and mental peculiarities of cretins consist in a dwarfing of stature ; imj^erfect development of the base of the skull ; a puffiness and swelling of the face, which is so marked in myxcedema, for, in fact, this disease belongs to the same group. The fingers are clubbed, and the tij^s spatulous ; the skin is of a dirty, waxy color ; the surface temper- ature is lowered ; the voice is high-pitched, raucous, or mufiled ; the hearing is defective ; the mind is dull, and there is not so much motor activity as in ordinary idiocy. II. BIBECILITY AND lONDREJ) DEGENERATIVE STATES. Mental weaknesses beginning during the fii'st years of life are apt to be unnoticed and neglected, and it is not until the third or fourth year that the parents realize that the real backwardness of the child is due to some defect in organization. It perhaps does not speak or walk as soon as do others of the same family, and possibly has a spastic gait, or does not hold up its head, but drools. This state may develop after an attack of convulsions, a febrile disease, or " brain-fever," or is associated with epilepsy. In other cases there is no such condition to explain its origin, and, in fact, the mental weakness itself may not consist in any- thing more serious than a '^ qneeiiiess " and perversity, which causes the subject to be looked upon as an unusually bad or an unusually clever child, or gains for it frequent and useless punishment, or adulation or injudicious praise when it has performed sonu^ difficult feat of mathe- matics or menu^rized some very long verse or piece of prose. To this class belong the nnisical and matheimatical jii'odigies. These children are usually correspondingly duU in other things, or grow up to be stupid men and women. The moral perversion which belongs to this kind of weakness is iiTegular in some ways, entirely beyond control, and is fre- 86 ^ SYSTEM OF LEGAL MEDICINE. quently ineradicable. The boy commits a cruel act of some sort, tortur- ing dumb auimals or even bis own kind; again, as in the Pomeroy Case, be actually commits wanton niui'der. Lying, steabng, indecency, and pui'poseless, impulsive acts are common. There is afterward little remorse ; the child knowing the abstract nature of its offense, often talk- ing about it, but feehng no shame. Occasion allj^ the subject is troubled by doubts and fears that constitute actual introspective insanity, and acts under the influence of imperative eoncej^ts ; but this is not common. The mental after-bfe may be a continuation of that of childhood, and if the grade of degeneration be such as to jDcrmit an actual attempt at progress and a battle with the world, it will soon be found how improp- erly equipped is the luckless individual. His school life is a succession of defeats and failures ; his business career is fitful and unsuccessful, and he soon di'ops out of the pushing crowd. His disordered moral nature gets him into trouble, while delinquencies, expressed in the direction of theft or petty crimes, lead him fii'st to the reformatory and afterward to prison. There is a very large number of jDeople in the community who mingle freely with their fellows, and whose real condition is not recog- nized. They are one-sided, imitative, and perform limited intellectual work where little inventive skiU is required. In some ways such peojDle are decidedly smart, and often indulge in feats of memorizing and tours de force which impress then- friends. Thej'' are, however, without sufficient reasoning power, and their judgment is bad. One of them may be a harmless person in every way, the butt of the town, the village wit, or he may be an exceedingly troublesome member of society, with criminal instincts ; in fact, a very large number of instinctive criminals are but imbeciles. So far as the physical make-up is concerned, we find peculiarities of head configiu*ation — what is known as " developmental ugliness " — stra- bismus, defects in the shape of the ears or teeth, eccentricity of dress, and tricks of manner and speech. The term coined by Guiteau is most often ai)plicable to these people, for they are often cranks in action and ap- pearance. An advanced grade of mental degeneration is manifested in disorders that run aU the way from "crankiness" or insane eccentricity to actual in. M0X0:\L4XIA OR PARANOIA. The use of the word " monomania " by various authors has led to much confusion. It has been apphed to forms of melancholia and mania, to inteUectnal insanity (Hammond), and b}^ others to a number of widely differing psychoses, ^y some it has been considered synonymous with '' partial insanity," that convenient legal excuse for criminals whose alleged irresponsibility is connected with mental integi'ity in all other dii-ections save one. From the fact of its being an expression of initial degeneration it has received the name "primarj^ delusional insanity." (Folsom.) Monomania or paranoia is an insanity in which the mental aberration consists in the existence of limited delusions that are either of a grand- ifjse or depressed or persecutory nature. The genei-al mental health of the subject is not always bad ; in fact, sometimes the pai'anoiac, except for his OAvn dominantly expressed delusion, may conduct himself with J.X^JXJTY IX ITS MEDICO-LKCAL liEAllIXaS. 87 death, as our inviolable rights and only legal settled citizen title, as registered in rem.. J. S., Justice. On the back of the paper appears the following : TAKE NOTICE. To all to whom it may Concern : That the Avithin is a copy of an order this day filed in the Clerk's Oifiee of the 5th; Judicial District Court, as this our home and international legally settled jusgentium measured inviolable privileged benefit, for the other nations and people of the other- sections of the globe, for all religious denominations and sects, and the various politi- cal parties and fractions and representations. You will please restrain and hold over,, and do the same bv signing same. N. Y., May 9th', 1883. JOHN SMITH. These and many others are familiar to the public through their ex- traordinary behavior, accounts of which have found their way into the newspapers; but the real condition, unless it is very pronounced, i& rarely appreciated. IXSAXITY IX ITS MEDICO-LEGAL BEARINGS. 89 The development of i)aranoiii is slow, and, as it has a congenital, neu- rotic basis, we find a previons life characterized by some of the early peculiarities of conduct alluded to in describinj^ imljecilit}'. The down- ward progress of the disease is slow but sure, the patient entertaining a limited number of delusicjns for many years before lapsing into dementia. The subjects are tolerated menil)ers of society, and not unrarely do much, good in directions whei-e their diseased intelleet does not interfere. Para- noia is essentially a ehronic disease, though lately a form has been de- scribed which is said to be acute. I am, however, disposed to believe that the very nuitter of time must exist to determine the natiu'e of the disease, for short-lived, single delusions, even with insane predisposition, may be found under other circumstances, and may symptomatize many ordinaiy acute insanities. It therefore does not do to speak of an acute paranoia. Suicide is not common, and homicide is resorted to only when delusions, of persecution or conspiracy exist, or when tlie person is being restrained or his acts controlled. A form known as Sensorielle VerriicJdheit exists when the limited de- lusion springs from some alteration of sensation and relates to the body; by some authors it has been called hypochondriacal paranoia. The following statement is that of an ignorant paranoiac of this kind whose disease had had a hypochondriacal beginning, and developed so that uns^'stematized delusions of persecution and conspiracy followed a period characterized b}^ the existence of limited hallucinations and cor- poreal delusions relating to liis own internal organs. He came from in- sane stock. The "Arenoughts" (Argonauts) were throughout respon- sible for his persecution. THE ARENOUGHTS. March lltli 1886 My Bowels Moved 3 times Before night parties or areiioiights, qiiite. quiat I com- menced Tacking the Medeson No 1862 . . . 3 11 86 Prescription from G R C Have taken the first dost in the evening 12th 1886 The parties threaton me with Blindness ; I have faith to Beleive G D L and J F F ; I Have ben threatond Several times before and a Blur Before my eyes Bowels Moved twice today now 8 Oclock at night I Beleive the parties Have power of My Mind and Brain and they have acnowladged thy have My papers and a Recept Book and a pair of Shomakers Pincers and Recepts of My Trade whiteh I Hope and Pray May Be Restoared back to Me And they further Have acnowladged they have ben Rested by Myfolks and that they are going to Noculate Me the same This said tonight the Twelfth Whiteh I think the Parties noculated My famely and went up to Be free from the law and Me By the fam- ely being put from Me by their commandments ; also they have claimed they are going to Mation Me for their Brother J F and all My acts of Mine and J F is not to Be found He J F agi'eed to Make Me clear of Debt if I would Stick to him until He got His Pentiou whiteh I Did and the contract was never done My Head and Chest Bounced like ones Hart after rimning fast a long distance at Night the Parties notime letting np entirely 16 they Sometimes punch ile at the root of My Tongue and other times at My toes and other times at My Heals. The parties claim tliat thare is nothing the Matter with them and Say that I was spirited So if they are blowed off they will come back or send Some won else as thy Now the Spirit in Me and can throw on me at any time Mr A What will be the expence to Have you and Me go to N Y city to a ^lition. Horsepittle or any Horsepittle and Have this Tested* Pleas Return this My Medeson 8 quorters used up * His urine. 90 A SYSTEM OF LEGAL MEDICLXE. March 20 1886 The arenoughts Say this Morning that They wont come S D on Me for I hant the Money to btildoze him backwards and forwards As 1 am thinking about a bill Dr L ast Me to pay yesterday ; While I was talk- ing with L the fiarties were operating on my Niu-vs so i trembled allover astho I was as cold as eoiild be without freezing; and they continue to operate on my ears daly; for thatmatter all over Me fi-om place to place ; A L Bill $10.50 cts; sui-- Tises 10th of Feb copy March 18 They say Im capable of Putting Him down And putting Him up in one Minute when they were Making Me shack astho Im Half froze Ive thought of bui'ning Sulf or in My Durtcellar and get in the back side will it Harm me if I sit in the bottom at the backside at the bottom My bowels scarcely any better Moving 3 or 4 times a day 20 while sitting in Sloats shop The parties up in The air said ; He Avont be able to plead His own cause so Splay And My Head Had a dull Heavy Ach and then spoke as thoug speaking to one in company with him Oh will He go to Adamses ; I feeling half asleep 21 They said That my place would be sold to findout whare My Money was and if I dident By it ; It would be given back to My wife and if I dideut Live with Hui" They would Murder Me and Saying that Mis Wimon was diseased by them and They were going to Mation or Mition them and My Money Had to pay them for it & tonite They were oijeratiiig on my body So I could hardly Breath Near my Xabol & felt as though it was Strained out ; near the same as ones finger in a Adee and turning Black with the preshure ; Xow as I am riting they say is he arny worse of than he was & the other says He would if we wasent Afrade of Adams ; 22 Tonite The parties commenced pumping on my Head up and down the Hollar of My Neck About whare the spine is and so down about as far as the bottom of my Sholder Blades. I think one could have seen My Head Move this done after I got in bed ; Soon as I got up to rite this they let up after I again got in bed they commenced to operate again I was thinking about going up to The Justice of the Piece and they said they would put me so low I eouldent pleed my own case I not nowing whitch to see first you or the oficer ; They said By God they did not now whitch way to do as they did not now whitch way I would go ; 23 My Bowels so loos it rujis from me like water I not Being able to now some- times before its dun ; IV. ADOLESCENT INSANITY. One of the critical points of life, when the mental equilibrium is most sensitive to disturbing agencies, is that of pubescence. It is at this time that the second period of brain development really begins. " Looking to the gradual development of mind up to pubert}', and the enormous and rather sudden leap that is then taken to"svard the higher mental life of the adult, we must assiune an ahnost completed apparatus Ijdng ready to be brought into use, just as the centers of respiration are read}^ for theu' functions at birth ; and considering that the very highest mental and moral qualities of all, wiih the subtle differentiation between the male and female mental tj'pes, are only fully seen between eighteen and twenty-five in the average human being, we must look still to the appa- ratus throitgh which all this is JDrought about in the brain cortex." (Clouston.) In cliildren possessing the insane diathesis a very serious and often incurable psychosis dcA'elops, and is apt to afterward end in dementia. In those with unstable brains various foi'ms of mental disease may appear much earlier than at puberty, and insanity in children of even five or six has been observed. The variety above alluded to, kno^^^l as adolescent insanity, is, however, quite peculiar. It is symptomatized by excitement, irritabihty, and impulsive acts, though melancholia exists in a fair jjer- centage of cases. The moral sense is blunted and sexual perversion is IXSAXITY JX ITS MEDIL'O-LECAL liEARIXGS. 91 common. The male sul)ject is insanely vain and conceited, bomhastic^ and ji'enerally m(>i'l)id. Some writers have desciibed the disorder as mas- tnrbatic insanity, beeanse the hai)it of onanism is snpposed to precede and canse the insanity. I do not think this term is proper, or the etio- logical theory of masturbation tenable, for the sexual vice is rather more apt to be the cause than the result. Various emotional disturbances are common in both sexes, and there is a certain periodicity which reseml^les foUe circuldire. A large numl)er of cases recover wholly or partially, though about thirty percentum lai)se into a profound dementia charac- terized by good physical health (primary dementia of youth.) The affec- tion must always be considered as a developmental psychosis. V. PERIODICAL INSANITY, {Folie Circulah'e; Alternating Insanity.) The clinical features of this form are reem-ring attacks of mania and melancholia, ordinarily in subjects with hereditary tendencies, though an acquired form is mentioned where states of elation or depression may be repeated. The attacks are separated by intervals of apparent lucidity, but it is a question whether the intervening condition is ever one of ab- solute integrity. The exacerbations seem to be due to internal causes, and are evidently the result of cumulative physical depression and mental disorder. The actual attacks of insanity tend to become more and more frequent, and eventually run together, the resulting condition being a terminal chronic psychosis, though this is by no means an inevitable consequence. Sometimes the attacks are always of melancholia or mania, or they alternate irregularly. The former are apt to be simple and not hallucinatory, and the delusions are often in regard to personal unfitness or are of a clearly religious nature. The delusion does not last very long, but rapidly disappears. The* remembrance of the attack is at first clear in the interval, but after subsequent attacks the mental condition and power of attention is confused, as it is in old epilepsy, and the recol- lection dim. When the character of the disease is excitement, such excitement is apt to be of sudden occurrence and subsidence. There is great irritability, shai'pness of memory, loquaciousness, self-aggrandize- ment, and morbid self-confidence ; incoherence and active hallucinations in a small number of cases. The feature of both mania and melancholia of this kind is the short duration of the separated attacks, which usually last but a few weeks. Seasonable factors seem to influence the changes that are observed, but it is difficult to say how. VI, REASONING INSANITY. {Reasoning Monomania; Monomania sine Delirio.) Many patients possess a remarkable abihty to con^dnce themselves, as well as others, as to the apparent consistency of more or less insane acts which they perform. Tliis form of insanity, therefore, is one that 92 ^ SYSTEM OF LEGAL MEDICINE. is apt to be the basis of litigation, because of the apparent intellectual \dgor of the subject. Its elements are originally false premises, from which he oftentimes reasons most logically, arriving at a conclusion which may amount to a powerful imperative concept. In most ways his ordinary mental conduct may be all that it should be, but the false in- sane idea exists, and is defended and justified with great vigor. Not unrarel}" the patient recognizes his weakness at some time or other, and undergoes great agony of mind. As the result of this dominating Mud of thought he makes purchases he can ill afford, or buys useless things, or is dangerous to society. His acts are often preposterous, but after their commission he is filled mth remorse and makes a manful effort to avoid the mandates of his specious conclusions. This disorder closely resembles the other affection which is expressed in the origination of morbid imperative concepts, and may be said to be an exaggerated form of that psychosis, as in it there is often a neurotic element or a history of alcoholism in other generations. The patients are usually adults. I have lately seen several children who, however, have developed the psy- chosis. A few months ago a boy of foiu-teen was sent to me who presented a form of this disorder, which I believe to be unusual, and which was due to improper religious training in a subject of defective organization. He studied hard and was ambitious, and, as a consequence, had developed headaches a year ago, with indigestion and general ill health. Some months ago his mother noticed that he washed his hands more fre- quently than usual, and that he would stand a long time before the basin in an apparently abstracted state ; that he would spit iii the coal-scuttle repeatedly, and that he picked up pieces of straw and matches, which were always tlu'own into the coal-scuttle. He explained his actions by saying that the pieces of straw resembled crosses, and he could not show disrespect by carelessly stepping upon them. His habit of spitting, he said, Avas due to the fear lest the saliva in his mouth should interfere with the fidl effect of the- communion-wine, and this was carried still further b}- spitting in his handkerchief. Of late he occasionally has de- lusions that his food is poisoned, but he denies this to me. When he crosses the railroad tracks that run near his house he is impelled to pick up stones that lie between the rails ; if he does not do so he is filled with fear lest there may be a railroad accident. He has all the distress of mind common to other sufferers from this form of trouble if he neglects to foUow his first impulses, and often returns to obey the dominant con- cept. He often remains for a long time* in the water-closet, sometimes for ten or fifteen minutes, and when his mother enters to find the reason of his seclusion, she discovers that he has littered the place with many pieces of discarded water-closet jjaper, refraining from desecrating by use anj^ piece that contains ci'cases that may bear any resemblance to the com- mon symbol of Christianity, he examines each piece carefully. He sleeps very badty and has nightmares, and grinds his teeth. His pockets, when examined, are often found to contain vaiious nails and sharp things that he has placed there after picking them up lest they might injure some one. When I talked with him I found little or no intellectual disturbance, and consider that his objections to his food were not so much because he IX.S.iXITY IN ITS MEDICO-LEGAL BEARINGS. 93 thought it was poisoned as IxT-auso it inig'lit in some way interfeve with liis rehgioiis professions and duties; but from Ijis motliont her; but, as in other cases of the kind, we find sympathetic friends and a sensation;d press ever ready to believe in aiid give publicity to tlie hysterical j)laint of the impostor. In this case the ropes that bound her were evidently applied by herself, and tlie quantity of cldoroform alleg-ed to have been used, a small bottle having been found (which it trans])ii-ed she had bought herself), made her story appear at once manifestly absurd. This case is unlike the last in the superficial character of the disease. Hysterical insanity is occasionally epidemic, and may appear as the result of imitation. Folie a deux., which is generally considered a more sei'ious form of insanity, is, I believe, nearly always of hysterical origin. I have known of one isolated and clear instance of imitative hysterical insanity in which two members of an unfortunate family became the subjects of a condition bordering upon hysterical mania. An hysterical girl was taken to the mountains for her health, but no benefit was de- rived from the change, and she grew more violent and unreasonable. Her mother, and a sister veiy nearly her own age, were her companions and constant nurses. Upon their return- journey to New York the sister showed an unnatural excitement, which developed before they reached Troy into a veritable hysteiical mania. They raved, and became so vio- lent that the hotel proprietor in that city turned them out of his house and put them on the cars ; but in Albany they again rested, and their sad condition being mistaken for drunkenness, they were arrested, but Avere finally released and again began their joiumey to New York, the mother being now in a partially responsible state, as she had been half crazed by the excitement and disgrace. They finally reached New York and went to a hotel, where they stayed for a night only, as one of the sisters tried to force hei" way through the fanlight over the door of her room, and so alarmed the guests that the police were called in and they were arrested and taken to headquarters. They were removed by some friends, and I subsequently examined them. The mental disorder in this case was sexual, and it became so much worse that the patients were finally sent to an asylum. In such cases as this the question of responsil)ility is an interesting one, and it is evident that the final action of the Albany judge, who first thought the patients intoxicated and afterward sent them out of to\Am, went to show that the behavior of the gii"ls was not looked upon as criminal. VIII. ALCOHOLIC INSANITY, Or, more properly, the insanity of alcohoUstn, is an acute or chronic condition pr-oduced l>y the toxic use of alcohol in its various forms. Wliere the alcohol is fortified by an essential oil. as it is under the forin of absinthe, the effects are correspondingly nullified. Acute alcoholism, or. delirinni, trenieiLs, does not properly come under the head of insanity, 96 A SYSTEM OF LEGAL MEDICINE. and is not ordinarily so considered. Its freqnent jDresentation as an ex- cuse for crime meets with no favor, for the law nsnally ver}' projierly holds that when an irresponsible state is voluniarihj produced, the indi- vidual is liable for his acts ; yet there are periodical drinkers whose cul- pability is certainly deserving the leniencj^ of juries. To this class belongs the dipsomaniac, whose excesses are separated by periods diu'ing which his conduct is irreproachable, and when he does lapse it is under the domi- nance of an insane appetite. The mental disturbance of acute alcoholism is the lively deliiium, visual hallucinations and delusions, motor activity, and exhaustion. Chronic aJcoliolic insanity is manifested by a train of progi'essive symp- toms of mental degeneration which vaay greatly. The most important indication of the prolonged saturation of the nervous organs with alco-. hoi is an impairment and weakening of the mental functions, conspicuous among which is the moral enfeeblement. The familiar change of char- acter is one that needs no description. Nervous irritability, the disregard of obligation, untidiness in dress, sexual perversion, lost sense of honor, manifested in lying and other directions, indifference as to domestic and social duties, are all every-day results of a prolonged abandonment to drink. Advanced grades of deterioration are manifested in the appear- ance of delusions, such grave indications of decay as continued depressed or excited states, and a dementia which resembles paretic dementia. The delusions of the chronic alcoholic are usually those of persecu- tion and suspicion. One quite characteristic is that entertained by married men regarding the chastity of their wives. Persistent halluci- nations of hearing are also present, are always of a distressing char- acter, and the patient may be urged to suicide by imaginary voices; -while sensory hallucinations which originate in the abdominal organs or those of generation lead him to believe in the occurrence of some horrible mutilation, and often in the removal of the testes. '' Hallucinations prevailed in 22.7 percent, of the recurrent cases of the criminal insane collated by Lewis in which alcoholism largely figured. The visual and aural in about the same proportion, and both associated in ;a few cases ; olfactory hallucinations or illusions were seldom noted, and gustatory were notably absent. Delusions occur in at least half the cases (53 percent.). Both hallucinatory and delusional states vary with the proximate cause of the outbreak : if alcoholic excess enters largely into the causation, we may anticipate associated ideas of self-importance, rank, power, wealth, and suspicion of perfidy upon the Y*avt of those around him. One patient receives a nighth' visit from his satanic majesty ; another sees imps around him, hears voices beneath the floor, the noise and rumble of machinery, which his morbid imagination frames into some idea of coming torture. Another patient, twenty-eight years of age, addicted, to intemperance in drink, and the subject of a serious cranial injury in youth, calls hhnself Sir Roger Tichborne, and accuses his relatives of filling his bedroom mth the vapor of cliloroform. An- other young alcoholic subject owns property "to the value of thousands a year," has extraordinary muscular power, and can " walk eighty miles a day continuously" (loe. cif., p. 215). Such physical symptoms as motor incoordination, trembling of the hands, facial muscles, lips, and tongue, are common. The tremor of the hands is worse in the early part of the day. After a time an actual INSANITY IX ITU ilKIH CO-LEGAL BEARINGS. 97 paralysis of tlie lower part of the bod}^ develops itself, and iw^y be at- tended by eraitips, deep pains, sug'^estive neuritis, or by an incoordina- tion, with plantar anaesthesia, wliieli often leads to the mistaken diajrnosis of loeoniotor ataxia. This anaesthesia is pretty general, espeeiallj' if the <}onsuniption of alcohol is constant, and points to a gradual inliamniation not only of the large nerve trunks, but of the ultimate filaments as well. The skin of the legs is apt to be "shiny" and smooth. Although some -of these symptoms may improve or disappeai- if the alcohol be with- drawn, there can be only one ending as a result of continued indulgence. The " paresis " of alcohol is very nmcli like classical paretic dementia, the delusions of grandeur, pei'haps, being more constant in the former, and the delusions of suspicion more systematized. The tremor is coarser and more general in alcoholic paresis. The gastritis of alcoholic paresis is of course not found in the other insanity, nor is the anaesthesia or the fulgurating pains (except in the ascending form which follows tabes spinalis). Paretic dementia is not modified by treatment, as is the variety under consideration.* The medico-legal importance attached to all forms of alcoholic insan- ity is fully proved by the frecpiency of cases where it is the issue. It is -alleged as a cause of testamentary weakness, or in fact where the assump- tion of an hnproper obligation arises ; and the protection of the courts is often sought for individuals who are said to be incompetent. In all of these cases the question of the existence, degree, and duration of the * Alcoholic InacmHii complicutcd iritli Fa- alysis. Headache. Active halhicinations affecting all tlie senses; disordered vision (illusions). Delirious conceptions depending upon liallueiuations ; ideas of persecution, ten- dency to suicide, evil instincts, conscious- ness of degradation. Embarrassed speech, depending some- what upon fear, upon startings of the muscles of the face, and especially upon tremulousness of the tongue. Feebleness, little marked, of the infe- rior members ; equal on both sides. Trembling of the hands and the arms, more marked in the morning ; formica- tions, cramps, and startings of the tendons of the forearm. Pupils nearly always dilated. Ana?sthesia of the extremities of the limbs, extending generally in the superior limbs to the elbow, and in the inferior to the knee. Sleep disturbed with dreams ; sometimes sleeplessness. Diminution of appetite, acid eructations, vomiting- of mucus in the morning. Diminution of the generative functions ; frigidity. Readily cured or modified. Occasional supervention of (Icliriiini trc- meiis. Paretic Dementia. Generally no headache. Enfeeblement of the understanding; rarely hallucinations. Ideas of grandeur and self-importance. Embarrassed speech, depending upon feebleness of the cojieeptions and paral- ysis of the muscles of the face. Feebleness of the inferior members, more marked generally upon one side than the other. Nothing appreciable in the superior limbs ; sometimes default of coordination. Pupils often mieqiual. often contracted. Sensibility normal, or obtuse over the whole surface. Sleep generally normal. Appetite augmented. Augmentation of the generative func- tions. Progress of the disease ordinarily rapid, always fatal. Tendency to congestions and to epilepti- form attacks. 98 -i SYSTEM OF LEGAL MEDICLXE. cause is to be determined, as "welL as Trhetlier tlie alleged iiTesponsibility is due to a comparatively rapid toxic origin, or the mental distui-bance masks a gradual and permanent disorganization. The connection of alcoholism "v^-ith insanity at Charenton has been studied by Thorneuf {Annales Medico-PsijclwJogique, 1859, p. 365), who thus classifies alco- holism : 1. Aciite alcoholic intoxication, in which the effect is always immedi- ately Knked to the cause, and the diu-ation of which is dependent upon the existence of the cause. 2. Subacute alcoholic intoxication, supervening to the immediate- action of the cause, usually melancholic in character. 3. Chi'onic alcohohc intoxication, which results in organic changes in the brain and nervous system, with accompanying insanity-. Of 350 lunatics treated in Charenton, when Dr. Thorneuf was an in- terne, the insanity in 102 cases was due to alcohol : of these. 15 percent, were of deliiimn tremens ; 6 j^ercent. were of di'unken mania : 1 percent, was of congestive mania : 3-4 percent, were of paretic dementia ; -4 j)ercent. were of folk circnlaire ; 2 percent, were of dementia; and the remainder- presented epileptiform con\*ulsions and anomalous psychical symptoms. IX. 3IELAXCH0LIA. This most familiar and common f onn of insanity is classified, with regard to its duration and clinical featui-es, as ac-ute and chronic, and clinically as simple meJancJiolia ; melancholia apathetica or afonifa, or stuporous melancliolia ; and melanclwlia agitata, or anxious melancliolia. Simple melancholia is a state which is accompanied by intense de- pression, mth painful delusions of a fixed but limited character, usually consisting of those which imply complete dejection and hopelessness^ and may lead the person who entertains them to commit suicide. Through a condition of impaii-ed organic memory there may be more or less loss of identity, or a false belief as to the identity of another. Among the commoner delusions that are tenaciously held is that of financial or moral ruin. The patient may in reality be a very rich or a very good man, yet he asserts that he is going to the poorhouse or is in danger of eternal imnishment. Such a form of melancholia is of slow development, and is preceded b}' continued ill health, loss of appetite and insomnia, which becomes more and more profound unless reheved. A natiu-ally happy and joyous person becomes sad, reserved, and takes little interest in her surroundings. There maj^ be an over-sensitiveness and a sense of per- sonal shortcomings and a feeling of self -depreciation ; the patient is tortured by doubts regarding her rehgious ^iews and her fitness for asso- ciation with others. She may imagine that she has committed some unpardonable sin, or that she is beyond help. She will not go to the communion-table, behe\'iug her presence there will pollute those whom she may meet; and one who has led a blameless and piu-e life may con- sider herself the lowest of women. In other cases the depression exists- in regard to more worldly things : the merchant will beheve that he is bankrupt, that he is dishonest, or that he is the special object of con- tempt among his business associates. The patient is slow in his actions, and moves sluggishly and with INSANITY IN ITS MEDICO-LKCAL JlEARINCiS. 99 Fig. 3:3. (Shaw). reluctance. It is with difficulty that liis att(nitioii can he aroused, and that his mind may be hxed for a slioi-t time upon some g-iven sul)jeet. If an effort is mad(^ to reassui-e liim lie is incredulous and as dejected as •ever. Tlie appearaii(;e of melancholia of all kinds is characteristic, and the physical symptoms are those indicat- ing^ the existence of anaGmia (Fig. 23). The skin is oftc^n harsh, diy, and jiale, as are the mucous membranes. The whites of the eyeballs are of a dull, flat wliite ; the pupils are dilated and slug'gish. The inner surface of the lids shows an absence of healthy vascular .supply. The tongue is flabby and in- dented, and the breath is vinous or bad. The finger-tips are usually rough, and there are hang-nails, which are due to ■defective nutrition and tlie constant haliit of j)ickiiig. The extremities are ■cold and clammy, with ])ooy reaction to rubbing. The hair is damp and limp. Occasionally the patient will pluck out the eyelids or the haii* from the head, with resulting deformity and highly characteristic change in appear- ance. Respiration is apt to be slow, as is the pulse. The patient may urinate copiously when excited or espe- cially anxious, and the excretion will be of light color and low specific gravity. Constipation is also characteristic of melancliolia. The surface and the deep temperature are lowered, the latter being often subnormal for long periods. Many patients complain of occipital or vertical pain and the sense of pressure, which are probably due to cerebral amemia. Hypochondriacal melancholia is a persistent form of disease which may be the outcome of ordinary hj^iochondriacal introspection ; the sub- ject ultimately beheving that a serious and material alteration has taken place in his internal organs — that his brain has been removed, or that his bowels are impervious, that his food ^'passes through him," that his ■semen is constantly escaping, or that the testicles are absent or that he is impotent. His false beliefs may range from simple systematized delu- sions to those of the most improbable and unsystematized nature. In some cases the condition resembles a primary delusional insanity. Graver varieties are stuporous melancholia and melancholia agi= tata. In the former the atony and depression may be extreme in tlieii' depth. The patient can be aroused with the greatest difficulty, and im- mediately resumes his constrained, fixed position and absolute silence. He often sits for long periods, occasionally sighing, and his external appear- ance is indicative of his mental torpor and bcAnlderment. Such patients will for hours retain morsels of food between then* teeth and cheeks, being too indifferent to masticate or swallow ; at times forcible feeding is absolutely necessary. Occasionally, especially in 3'outliful subjects, there will be a tendency to catalepsy, the muscles of the extremities being 100 ^ SYSTEJI OF LEGAL ilEDLCLNE. at times so rigid that it is possible to put the members in constrained positions which, are maintained for a long time. The profound depres- sion is sometimes varied by fitful flashes of intelligence or some impalsiv& act, -^'hich is as likely as not to be siucidal. These patients upon recovery are able to recall the delusion, and its influence which has possessed them. Melancholia agitata or anxious melancholia is one in which excite- ment plays a part. The patient is always tortured by some distressing^ delusion, with attendant painful emotions. Restlessness; "^dolence, and often suicide or self -mutilation are exhibited or resorted to. The patient is active by day as well as night, can be taken care of only with the greatest difficidty, and wears himself out in useless effort. Delusions, hallucinations, and illusions are ever ^^resent, and auditory hallucinations are the most torturing. The patient is told to do certain things by voices that come from water-pipes and holes in the wall. Visual and sensory hallucinations, too, add to his mental terror. His bed swarms with im- aginary vermin. If he be suspicious that he has been poisoned, he will make more or less successfid efforts to vomit, and call attention to the escape of the worms and " microbes " that he throws up or the snakes that crawl over the floor. In some ways the delirium of acute alcoholism is some tunes suggested, at others it approaches the excitement of mania; but in the former there are actual persecutory delusions and in the lat- ter there is incoherence, due to the rapidity of outside stimulation, Avhich reflects the elated and pleasui-able state of the emotions. There is rarely any disposition to the infliction of injm-y in melancholia, except so far as suicidal attempts are concerned. These are common, and the results of the hopeless delusions and hallucinations. So far as the physical disorders relate to the mental state it is the fact that there is much more general constitutional distiu'bance with anxious melancholia than any other form. Some of it is due to want of sleep, and to the attempt at ^'oluntary starvation which springs from the delusion. Chronic melancholia is the natui'al outcome of a continued depres- sion which need not necessarily end in dementia,. Sometimes, esjjecially in the sexual forms in women, the chronicity is attended mth a great deal of reasoning acuteness, and what Eji'chhoff calls a folie raisonuanfe in a melancholic form, -Rdth alternate depression and angry excitement. Melanchoha is often ciu-al>le. The fii'st danger of exhaustion from star- vation is the only one likely to Ining an early fatal termination, except it may be suicide or intercurrent disease. If the patient's disease lasts one year it is apt to he permanent and incurable. When it originates at periods of sexual development, such as pubert3^ at childbirth or the cli- macteric epoch, it is rather apt to b^ obstinate. This is especially true of the puerperal form. X. 3IANIA. Mania, like melancholia, is an acquired insanity, though under certain conditions it may symptomatize both evolutional and involutional insan- ities. So far as its duration is conc(^rned, it, like the depression psychosis, may be either acute or chronic. The term suhdcnfe, sometimes used, has, I think, no clinical value. It is eminently a mental disorder of expan- sion, and is characterized by excitement of greater or less violence and IXSANITY JN ITS MEDICO-LEGAL BEARINGS. 101 coiiljiiuiince. Like mcL-UK'liolia, it is apt if not cured to end in termiuid dementia. The emotional activity and intelle(;tual exaltation are niani- fe«t(!d in a rapid ilow of ideas, which are not inhibited, and tin; result is incoherence. Acute mania is often of (juite sudden development, thoiig'li usually the way is paved by some decline in the general health. In the cases that usually come under notice a histcny of alteration in mental health is evinced by an exhilaration and liveliness which con- trast with the ordinary habits of the patient. The apparently increased mental activity is disorderly, and the exercise of intellectual vigor sj)as- modic. His self-satisfaction and sense of importance prompt him to enter into schenu's moi-(; or less wild, his generosity is exuberant, and he makes the grandest promises, without any idea as to how he shall fidhll them. If he is crossed or doubted his anger is quickly aroused, Init short-lived, and the affront is forgotten immediately. His mind seems to be a kaleidoscope of ever-changing ideas, which later become more and more confused. He is restless, forgets obligations and appoint- ments, sits up until late, and sleeps but for an hour or two, and after- ward not at all. He gesticulates, and his manner is hurried and impetuous. His letters rellect his tops3^-turvy state of mind and re- fer to his schemes. These are often innumerable, and he writes to every one he has heard of. The telegraphic wire is kept busy with irrelevant or unnecessary messages. His dress reflects his condition, for he is slouchy, and his clothes are carelessly put on and often unbuttoned. Some- times he orders and wea.rs gar- ments that are extravagant in color and shape, and affects a style that brings him into notoriety. His features now indicate the excitement under which he la- bors, for his facial muscles twitch, his eyes are prominent, his face is flushed, and his pupils are di- lated and mobile. The patient will bus}^ himself doing and un- doing, fussing, and arranging and rearranging furniture, clothes, or other tilings. A'arious moral changes appear in conversation and conduct. These vary greatly, and the commission of shameless acts, the making of indecent proposals, or, at a later period, when the incoherence and confusion prevail, the defilement of himself with faeces, are common evidences of loss of con- trol or evidences of sexual irritation. As the psychosis becomes more and more pronounced, the patient becomes nK)re frivolous in dress or absolutely indifferent. He occasionally decoi-ates himself with fantastic objects. One of my patients, who was the suliject of chronic mania and had acute exacerbations, was in the habit of putting on a white satiu Fig. :.'t. 1 1 1 102 ^ SYSTEM OF LEGAL MEDICINE. ball-dress when she arose, and loading her neck and wrists with dia- monds. She would give herself up to amorous thoughts and conversa- tion, and write erotic letters and poetry to men she knew but slightly or not at all. So-called kleptomania is apt to be an incident of such develoj)- ment, and it differs from the kind due to imperative concepts by reason of the fact that in this disease the intellect is disordered. The thefts are of all kinds, and bits of worthless rag, keys, l^its of glass, or trifling objects are stolen and secreted very much as a magpie would. The patient is also at times prone to indiilge in low vituperation, and makes use of oaths and expressions which are so foreign to the normal moral integrity as to make every one wonder where they were learned. Young, innocent girls will repeat ford words of the gutter and cannot be re- strained. When the disease has increased to the point where the excitement is intense and the patient is incoherent, the hallucinations, illusions, and delusions are dominant and so active as to suggest delirium. All forms of intense motor acti\it3^ make themselves apparent in violent muscular movements of various kinds — cries, shouts, loud singing, laughing — or in automatic movements which are repeated for a long time. Sometimes the patient declaims energetically, flourishing his arms, and walks bombastic- ally up and down. Sometimes there is an exaggerated di-amatic power of expression, a simple act being performed in a grandilocpient way. He decorates liimself, as well as his room, with odd objects, mixes up his food in a disgusting mess, and eats ravenously. His hallucinations fol- low one another with great rapidity, and he has frequent conversations with imaginary people he sees, which are not interrupted b}^ the casual entrance of a visitor. Sometimes the illusions result in a loss of identity, the patient believing the visitor to be a relative, a lover, or some improb- able person. He is shoWered with kisses or is the subject of demonstra- tions of the most marked kind. Local anesthesia or hypera3sthesia, the former of which consists in in- sensibility to extremes of temperatiu'e, and the latter to headache and subjective discomfort, may be mentioned as symptoms. This heighten- ing of sensation may be the origin of olf active hallucinations, which are present in about fiftj^ percent, of all cases. Fig. 24 represents very well the expression of exaltation so characteristic of this form of insanity. Mania is nearl}^ always preceded by some depression, and the activity of mental operations which is sometimes evinced by a revived acuteness of memory must be looked upon with suspicion. After the continuance of the acute condition, whieli is expressed by the impulsive conduct and is variable in dm-ation, we find convalescence and ultimate eui-e, or a clironic mania or terminal dementia. The duration of cases which are to get M^ell is variable, the time varying from a few weeks to a year. Stearns says that when a case has passed the twelfth month it is to be regarded as chronic. This, I think, is the generally accepted conclusion, and a safe prediction. When a case becomes chronic the mental condi- tion is often one of extraordinary evenness, though all sorts of disorderly manifestations may occur from time to time. The chronic maniac of asylums is usually a moderately noisy, active patient, who always has a collection of rather imiform delusions and hallucinations which are eas- ily evoked, and the former tincture the manner and are shown in dress. There are other patients whose unsystematized delusions become more IXSAXITY IX ITS MKDIVO-LKUAL BKARIXGS. 103 and more (lisoi\t>;uiized and absurd, and whose incoherence is not con- fined to any ])art of the day or night. Some who present the incurable form of this disease are liarndess enough, and are capal>le enough to do farm-work requiring little or no individual exercise of judgment. Ac- d to busin(^ss, to which he had been f()rin(Mly devoted ; he speculated and lost his savings ; he mani- fested antipathy toward his wife and two out of his five children, and 106 -^ SYSTEM OF LEGAL MEDICINE. saw liis whole family reduced to penury through his own rashness and neglect without displa^dng any compunctions. When complete pecuniary ruin had been effected he suddenly became himself again, and resumed industrious ways, but ever since he has had attacks of restless exeitabilitj^, with hatred of his wife and children, twice or thrice a year. He is at all times intelligent, rational, and free from delusions, and when at his best period joins his relatives in deploring the sad visitations to which he is liable." (Browne.) Dr. Charles H. Hughes {American Journal of Insanity, 1875) alludes to the peculiar mental state of dualitj^ which sometimes follows head in- juries — a condition in which one hemisphere apparently fills a vicarious office. He refers to a case presented by Joffe, and gives the main points of the histor}'', which is the following : " He was a married man, aged fifty-three, healthy in childhood and youth, in manhood had headache and giddiness ; was a soldier fourteen years ; in encounters with smug- glers received several cuts in the head. His temper was irascible ; he was fond of drink, had hemorrhoids and constipation for ten years. Disposition serious. His memory failing, he became unfit for service and was discharged in 1861. His pecuniary circumstances caused him great anxiety, and in the same year (1861) he exhibited unmistakable signs of mental disturbance. He continually employed the expression ' we ' — ' we win go,' ^ we wiU run,' ' we wiU do it,' etc. The ' other ' man pulled his ear, plucked his arm, etc. His left arm had spasmodic twiteh- ings. He invited himself to dine with his sister, saying that the ' other man ' compelled him to be her guest. While eating he said, '■ I have eaten enough, but the other has not.' After the meal he ran out of the house ; when arrested said the ' other ' was to blame — he was doing what he could to make him stop. Tried to murder a child, assigning a similar cause for the attempt. He rolled into the gutter, thinking he was wrest- ling with ' the other,' and finally attempted to commit suicide, imagining he was killing ' the other.' This brought him to the hospital. The con- formation of head was normal, pupils contracted unequally, reaction to light in both limited. Hearing normal, but saw small animals, insects, etc., with left eye, and vision dim in right eye. Tearing pains in left ear and side of face. Physiognomy anxious and expressive of suffering. Skin dr}^, and temperature and sensibility of body natural. Pulse sev- enty-eight. Reflex movement to tickling soles of feet prompt. No digestive trouble. " The ' other ' person was in his left side under his skin. He called himself the right D (D was his name) ; the left D was a rascal and caused aU his misfortunes. He sometimes presented the picture of anxiety, dripping with sweat, and holding fast his shirt with both hands, in order, as he said, to make himself stop. He had violent impulses to motion, lasting an hour or two, occurring several times in the com^se of six weeks, and which were probably epileptic or epileptoid seizures. After conversing some time, long enough probably to weary and morbidly disturb the sound hemisphere, his ideas grew confused, and it was impossible to gather any sense from what he said. " He died of dysentery, and during the progress of the disease had no apparent delusions. ' The autopsy revealed a thickened dura mater. On the left side of the falx there was a lamina of bone half an inch long and a quarter of an inch broad. The membranes along the course of IXSAXITY IN ITS MEDICO-LEGAL BEARINGS. 107 the vessels were opaque, infiltrated with seriiin, their veins quite full. Convolutions of the anterior lobes, especially the left lobe, very mu(;h thinned on the convexity — left anterior lobe half an inch shorter than the right. Anterior half of ventritde of this side was adherent and liard. Optic thalamus and corpus striatum atrophied — especially the lattci-. Brain moist, aiupmic, tough. Epeudyma of the lateral ventricles tliiclv- ened and granulated, corresponding to the thinned convolutions of tlu^ anterior lobe. The cortex was thinned, and the adjacent medulla was indurated to the touch.' " The loss of memory that may occur after cerebral injury may or may not be connected with other symptoms of insanity. When we consider that the lesion may vary from a simple ischemic one, due to concussion, to a minute and general disorganization of the brain substance, it is reasonable to expect widety varying symptoms. Bell arranges the de- fects that may follow a cerebral traumatism as : "1. An instantaneous unconsciousness, that is to say, loss of recognition of one's individuality, followed by giddiness, stupidity, foolish talking, etc., which may pass off sooner or later, but still is in immediate relation to the accident, and gradually disappears. 2. A set of phenomena very various in nature and amount, beginning a few hours after, and depending on structural and inflammatory changes in the cranial contents, feverishness, delirium, di'eams, etc., passing off into fever or lapsing into coma, from compres- sion : if from hemiplegia these may be very rapid ; if from meningitis they may be slower, and the development is to be counted by days and weeks. 3. A state of phenomena of a much lighter and more dangerous character, beginning with structm-al changes in the cranial contents in the direction of atrophy or softening, where you may have delusions, loss of memory, paralysis, and dementia." He alludes to numerous cases where, in addition to the above, the patient had forgotten entirely, not only the circumstances connected with the accident, but '' a certain length of time, varying in different cases from minutes up to hours and even days, with all its actions, pains, and pleasures, before the accident hap- pened." A recognition of this condition of affairs is of immense impor- tance in those cases where testimony is given concerning the details of the accident, and a strong point is very often made (and sometimes un- justly admitted in court) that the story of the patient is false, because he cannot remember the manner in which he was injiu'ed, or his beha\dor at the time ; and it may perhaps be insisted that he was drunk, when such was not the case. After surgical operations of various kinds the subject may suddenly develop a coufusional insanit^y, which is short-lived, and violent while it exists. Whether due to shock, loss of blood, or reaction following men- tal apprehension, it is difficult to say. It would appear that g^Tiecological operations in particular are those which are most frequentlj^ followed by the lighting up of mental symptoms. XIII. POST-FEBRILE INSANITIES. The fevers and other diseases in which exliaustion has been great, or where pathological destruction or injury has invaded the brain, may be followed by insanities which rather suddenly make their appearance, 108 ^ SYSTJiAl OF LEGAL MEDICLXE. either at the tiu'ning-point in the particular affection or dm-ing conva- lescence. There is no regular expression of symjjtoms, and illusions, liallucinations, and delusions, which are generally unsystematized, ai-e irregularly expressed and are varied. Sometimes the condition, by rea- son of its incoherence, is confused mth delirium, but unlike the latter is inconstant, and seems most pronounced in the night, the patient being fau'ly in ]30Ssession of his faculties during the daytime. The M^riter has seen several cases of insanity after typhoid fever in which the sjTnptoms appeared one or two weeks after the subsidence of the symptoms of the fever itself. In one of these eases there was wild incoherence, a rise of temperature, and refusal of food. A few of the cases become chronic or run into dementia, but as a rule they recover gi'adually, and sometimes suddenly. Xn\ DE3IEXTLA.. This degeneration, which when it occui's always implies the beginning of the vital end, may be the result of a continued simple (acquired) form of insanity, such as melanchoha or mania, when it is known as secondary consecutive dementia ; a disease by itself, when it is known as jJi'iinary de- mentia, paretic dementia, and senile dementia; or a result of destriiction incident to such forms of coarse brain disease as hemorrhage, embolism, or thrombosis. All forms of dementia depend primarily upon the loss of stored-up impressions • in other words, an actual deprivation : in this respect de- mentia differs from amentia, where no develoj)ment has taken place. Its extent depends upon the richness and variety of stored-up concepts, and its progi-ess upon the acquii'ed degree of automatism and the habitual regulation of concept stimulation and coordination. Memor}^ is impaii'ed proportionately with the degree of enfeeblement, and the involution, which keeps pace T^ith the advance of the disease, implies, fii'st, a loss of memory of substantives, a blotting out of recent impressions, and a re- tention for a time of those acquii'ed before the destructive eifects of dis- ease had begun to extensively make themselves felt. In comparatively recent cases old concepts are recognized, expressed, and acted upon, while new percepts make fugacious impressions or none at all. The business man will automatically follow out the routine work of years, while new creations are impossible and other forms of capacity may be lost. An isolated instance of ability and shrewdness T\-ill be urged as an index of the mental health of the alleged lunatic, when he occasionally correctly perfoi'ms some long-learned and frequently prac- ticed act. Ultimately everything goes, and the mind becomes a blank, and the dement is physically and mentally slow and inactive. He later becomes little more than a child, "^-ith aU of its weaknesses and silliness and irritability. He is occasionally petulant, and sometimes ^dolent in a weak way. W^ien the disorganization has sufficiently advanced the patient sinks into a vegetative state, disregarding the ordinary decencies of life, urinating or defecating in his clothes, or masturbating publicly. Tlie posture he assumes is usually one of relaxation, or in old cases actual rigidity due to his maintained posture. He sits bent forward, his eyes fixed upon -s'acancy, or they are a^'eited, whUe the saliva drools from the corners of his mouth in a e:lah-v stream. INSANITY IN ITS MEDICO-LEGAL BEARINGS. 109 XV. SENILE DEi^IENTIA. This term has been appUed to a variety of primary dementia occur- ring: in aged people, the word primary being used to denote an origiual condition, and not a disease wliich is a seqnence of other inorbid states. It is rare before sixty, and when it occurs hiter in life is difficidt to dis- tinguish from the natural decay of old age. Its early symptoms may be depression or exhilaration, amounting on the one hand to simple melan- cholia, or on the other to a light grade of mania ; or there may be nothing else but an apparent increasing mental feebleness, with loss of memory, irritability, and superficial delusions of suspicion and persecution, and he is apt to believe that he has been robbed. He conceals and hides his papers, or puts useless objects he may have hoarded in out-of-the-way places. He may tie a stone or cigar-end in his pocket-handkerchief, or secrete bits of thread, buttons, etc., in his different pockets. He is wake- ful and is inclined to wander from room to room during the night, or away from home, and, like a young child, is afterward unable to give much account of himself. His unconcealed immoralities are noticeable, and he indulges in orgies, and may hire the entire personnel of a house of prostitution for a sexual debauch. He makes indecent advances to little girls or boys, exposing his genitals in the streets. In a more ad- vanced form he urinates publicly and ostentatiously ; is careless of his dress, leaving his trousers unbuttoned. He is vacillating, and apt to squander his money recklessly ; enters into absurd schemes, or gives his property away to persons who have no claim upon him whatever. He is the prey of sharpers or confidence men. His erotic excitement "\vill often subject him to the arts of designing women, who for one pui'pose or another seek to gain control of his property. Such old men are apt to marry women many years their juniors, and to resent the interference of their children, upon whom tl}ey turn, often disinheriting tliem. In fact they are inconsiderate and without affection. Sometimes their sexual weakness leads to the wi'iting of love-sick letters to numerous women at the same time, the wi'iter being unconscious of the ludicrous position in which he has placed himself. The mind toward the end becomes nu^re and more weakened, and the patient sinks into an exhausted condition and finally dies. XVT, PRBIARY DEMENTIA (OF YOUTH). Primary dementia, so called, is a somewhat misleading synonym for stuporous melancholia ending in dementia. It has Iw some been applied to the dementia of adolescent insanity. Spitzka classes this dementia and W\^t of senility together, very properly believing them both to be involutional degenerations — in which conclusion I am disposed to agree. Acute dementia has been spoken of, and has been used to designate that form of rapidly developing mental weakness so common sometimes in youth. These patients, as a rule, manifest a depression, with introspec- tion and silliness. The depression deepens into a state of hebetude, with silence which is so pronounced that it is often impossible to draw forth any response. The young subject nuiy be indifferent to his surroundings and to all the demands of nature. Occasional!}' such dementia is pre- 110 A SYSTEM OF LEGAL MEDICLNE. ceded by an insanity which consists of elation, inordinate conceit and vanity, rehgions doubts, and sexual aberration manifested by masturba- tion or onanistic hypoehondi-iasis. A degree of forgetfulness and confu- sion follows this. There are not necessarily hallucinations or delusions. x\t:i. paretic dementia. {General Paresis; General Paralysis; Dementia Paralytic.) This important disease is of a progressive natui'e, runs a compara- tively rapid course, and is symptomatized by important departures from the normal psychical and physical condition. True paretic dementia is a disease of adult life, though exceptional cases have been recognized in childhood as a result of congenital syphilis. Such an one is that observed by Clouston. Paretic dementia runs a course which is comparatively characteristic, but two forms of mental disease closely resembhng it. One is " alco- hoHc general paresis," which is an irregidar form of chronic alcoholism j the other " pseudo-general paresis," which is due to active coarse cerebro- spinal destruction, due to syphditic infiltration, and the spinal symptoms are as important as the cerebral. Some writers have sought to make close differentiation of forms which have a syphilitic origin from others with no such basis, but I believe this to be a difficult matter. Paretic dementia is a disease in which conspicuous mental and phys- ical symptoms are presented. Beginning with slight alterations in man- ner, which are often disregarded or mistaken, and with very subtle phj'sical changes, the affection very rapidly advances, so that before many months there can be no doubt as to its nature. It nearly always follows dissi- pation, remote syphilis, or high living, and is modified by alcoholism, though undoubtedly in a few patients no such, causes exist, and irregu- lar mental overwork is sufficient to account for its genesis. In America, especially, we find that the unreasonable haste to accumulate riches, and the overvaulting ambition to keep abreast with the more successful, have had much to do with the development not only of nervous diseases in general, but paretic dementia in particular. The appearance of symptoms is somewhat irregular. In a large num- ber of cases we find a preliminary depression which has a hypochondri- acal tinge, and this is common where there is early alcoholism, and is as- sociated with hopelessness and simple melanchoha. In others the early active symptoms are expansive, and in a third class of cases shif tlessness and forgetfulness betoken a departure from the normal mental health. Sometimes a convulsive attack will be the first thing to impress the friends of the patient with his real state. The usual mental change, after care- lessness in appearance and habits, may be a boastful vanity which ren- ders the individual ridiculous, when mere lying is followed by the wildest Munchausen braggadocio. He will perhaps tell you that he has horses which are faster than any in the world ; that his diamonds exceed in value the crown jewels of all the European courts ; or that he has made impos- sible explorations and voyages. Later on he grows more expansive and reckless in his statements. One man told me that he had hired Patti, Nilson, and aU the great prima donue, and had built an opera-house ten IXSAXITY IN ITS MEDICO-LEGAL BKAIIIXGS. HI miles long; another that he could speak all the known hmguafres, in- cluding Arabic, Sanskrit, and Hebrew, although he was a printer witli scarcely any education of which to speak. Many paretics believe them- selves possessed of extraordinary physical force, and avow their power to lift the heaviest weights and perform the most extraordinary feats. The grand delusions of some take the form of sexual capacity, and it is not rare; to find them boasting of powers that excelhid those be- longing to any of the personages of the Old Testament who possessed innumerable concul)ines. With tliis there is foolish extravagance and the purchase of useless things. One num will conti-a(;t for property for whic^h he cannot pay, or Ijuy numljcrless pictures for which he has no use, lie will order large quantities of jewelry or precious stones. He resents interference and the counsel of friends with violence, and plunges into the wildest excesses. He deljaiu-hes himself and consorts with pros- titutes, and no form of bestiality satisfies his desires. At this time it will be noticed, perhaps, that his pupils are uneqrudly dilated, one being larger than the other (usually the right), or that ili&y are contracted to the size of pinheads. His tongue, when protruded, tremljles slightly, the tremoi' being fine, and accompanied with sudden retraction of the whole organ when the effort is continued to keep it protruded. As the disease advances the lips in turn become tremulous, and the corners of the moutli uneven. The speech is clumsy, and there is great difRculty in pronouncing the labials and lingual consonants. The mental state keeps pace, and the delusions are more marked — they are, however, occasion- ally concealed, but this is rare. It is c their parent as of unsound mind. In the case of Hartwell vs. 2r Master (4 Redfield, 38) it was shown that the deceased executed his "wtH on September 25, 1880, and died October 1, 1880, aged seventy-two years, leaving no children. He had been in business in New York City, had taught school, preached, and had some knowledge of electricity. On behalf of contestants it was claimed that testator lacked testamentaiy capacity, and it was shown that he did not believe in the doctrine of the " real presence " or transub- stantiation, nor in the necessity of baptism in infancy; that he lived alone and locked himself in dm-ing his last illness ; that he had once disturbed a religious meeting by abusing the minister ; that he wished to attend a i^ublie school as a pupil ; that when over sixty years old he fell in love with a girl of twelve. It was very properly held that these things alone were not sufficient to prove that testator was insane or lacked tes- tamentary capacity. The Influence of General Diseases. Bodily disease may result in an insanity that may destroy the dis- posing powers of the individual. Such somatic insanities as that due to Bright's disease are frequently referred to, but more often great stress is laid by counsel upon the existence of the cerebral symptoms of this old at the date of the will, was eeeentric, fickle-minded, continually interfering with and scolding with workmen about her house. It was also shown that a sister of Mrs. King, who died in 1863, had been insane, and had several times from 1840 to 1858 been placed in retreats. She could not remember from one day to another when she had taken a bath, and frequently after ordering meals at a restaurant (in 1884) denied that she had ordered the food that was brought to her. She continually comiilained of aggravated stomach trouble, and shortly before her death ate a bowl of chicken broth which she had kept in her room for three days, and which was not fit to eat. {Sic.) A few days thereafter she died of dysenteiy. A fjost-mortem examination showed no chronic stomach disease. At one time Mrs. King was a patient at a sani- tai-ium. Dr. Gallagher, one of the attendant physicians, testified that he took pills to her ; she would not take them — said they were flies' heads. He then got a fly's head and she took it. The proliate of the will was disallowed, and on appeal the Supreme Court reversed and ordered a new trial (88 Mich. 567). On rehearing the judgment of reversal was upheld except as to costs (93 Mich. 234). IXSAmTY IX ITS MEDICO-LEGAL BEARINGS. 121 and other diseases, and their effect upon tlie eonduet of the individual. Very often such petitioners are apt to forniuhite deeidedly orijiinal \ iews regarding the pathoh)gy of the conditions, and to draw unwarranted conclusions therefrom. Such was the issue in the Jesse Hoyt Will Case, where great contention was caused and much irrelevant testimony given regarding the morbid anatomy of the kidneys. Beyond the irri- tahility, stupidity, aphasia, and very rare epileptic conditions, nothing can be shown ; but when we consider tlie renal disease, with cardiac disease, as precursors of actual degeneration of the cerebral vessels, it has a decided importance. The demonstration of the connection between emljolism or cardiac disease with cerebral softening and dementia, of syphilis with paretic dementia or epilepsy, is of the greatest moment. The distrust of the courts in considering sitcIi matters is often shown. Wlien the will of the late Alexander D. Fraser, of Detroit, was contested^ the issue was raised that his testamentary capacity had been destroyed by cancer. The will was dated May 17, 1877, and the evidence showed that the deceased was over eighty years old and had been suffering for over twenty years from a cancer on the nose, which ultimately consumed the flesh on one side of his face and also his eye, and from which he finally died on August 2, 1877. Prior to the winter of 1876 he had been very fond of societ}^, had always been neat in appearance, and kind and considerate to the members of his household; but after that time he secluded himself, became slovenly, and frequently abused and assaulted the members of his household. He was eccentric in dress, and at the execution of the will appeared attired in a night-gown and Scotch cap. After the execution of the will (in May, 1877) and up to the time of his death he frequently had delusions and raved to such an extent as to dis- turb his neighbors. On these facts five physicians beheved him insane. On a trial before the jury a verdict was rendered sustaining the will, which verdict was, on appeal to the Supreme Court, affirmed. (-42 Mich- igan Reports, 20G.)* Cases Avhicli are familiar, and Avhere, as a rule, there is sufficient dis- ease of the structure of the brain to effectually weaken the mental powers to the degree of irresponsiljility, may be illustrated by the following: Sarah M. Blakely executed her will April 7, 1876, and it was con- tested by her husband on the ground of insanity. It appears that she had a stroke of apoplexy in December, 1875, and for some time there- after was subject to pai'oxysms of grief and crying. In April follo'wing' she executed the will. In the summer of 1876 she had another stroke of apoplex}', and on Septemlier 26th was sent to an insane asylum, where she died March 10, 1877. In February, 1876, she ^^Tote several clear and coherent wills. For a long period she had manifested a great dislike for her husband and entertained groundless suspicions of him. She was nervous, flighty, excitable and hysterical, discontented and unhappy. Dr. Barnett, who attended her, says that after the paralytic stroke in December, 1875, her mind became enfeebled, and that she was suffering from dementia, and he did not consider her in a proper condition of mind to attend to business in the spring of 1876. Drs. Hunt and Russell testified, as to her condition before the paralytic stroke, that her conduct might be the result of nervous excitement or childishness. Dr. Kemp- * Also sec Ifairs vs. Freeman, 3 Redfield, 181. 122 A SYSTEM OF LEGAL MEDICINE. ster, superintendent of the asylum in which deceased Avas confined, from an examination made in September, 1876, believed her to have been of unsound mind in April, 1876. [BlaMij Will, 48 Wis. 294.) Seth H. Evitts died September 22, 1877, aged eighty years. On August 27, 1875, he executed a mil, bequeathing to plaintiff all his prop- erty with the exception of a few smaU items. On April 2, 1876, and September 22, 1876, he made two other wills, which were substantially the same as the will of 1875, the only change being in the minor be- cpiests. These wills were severally offered for probate, but rejected on the ground that testator was not of sound mind when he executed them, and the will of 1875 was probated. On December 20, 1876, deceased exe- cuted a deed to defendants, transferring most of his real estate. His deed it is now sought to set aside on the ground of mental incapacity in the grantor. In setting aside the deed the Maryland Court of Appeals said, in reviewing the evidence, that after the execution of the win of September, 1876, the defendants, through false statements, produced in the mind of deceased an insane delusion that plaintiff was treating him badly and robbing him of his property ; that he had always been on affectionate terms with plaintiff ; that there were no grounds for the delusion ; that he had several strokes of apoplexy in 1876, and was permanently paral- yzed ; became imbecile ; was childlike ; had few ideas ; his mind became inert ; was easily controlled and influenced ; his memory failed ; was un- able to walk without assistance and required constant attendance ; his hobby was politics. (CJierionnier vs. Evitts, 56 Maryland Reports, 276.) Epilepsy. — The wills of epileptics are sometimes contested. In the €ase of Ross (12 N. Y. Weekly Digest, 34) the will was made in an inter- paroxysmal period and was sustained. On Ajjril 29, 1879, the testator, who had been subject to attacks of acute mania, superinduced by epilep- tic convulsions, was committed to a lunatic asylum. He was discharged May 12, 1879. The superintendent of the asylum testified that testator's mental condition was then good, and that between the eijileptic attacks he was of sufficient mental soundness to understand what he was doing. On May 21, 1879, testator executed his wiU. His familj^ physician testi- fied that he was then of sound mind and memory, and capable of making a wUl. Testator was again attacked with an epileptic convulsion on June 11, 1879, and died June 24, 1879. Held that testator was sane at the time the will was made. The following case is somewhat more complicated, pneumonia with delirium occurring at about the time of the execution of the will : Elizabeth M. Riggiu was, on November 14, 1868, at the age of sixty- two, attacked with an epileptic fit, and rendered unconscious ; an attack of pneumonia supervened the epileptic fit, accompanied with high fever and occasional delirium, during which she would be unconscious. Pre- vious to her illness she was intelligent and cultivated, robust and strong, though nervous. She was regarded as a gifted and brilliant woman. Witnesses on both sides, who were present during her illness, stated that while occasionally out of her mind, at other times she was rational and intelligent, her mental condition being cleaily the result of delirium attendant on high fever. No witness claimed that she had wholly lost her reason at that period. On November 23, 1868, she executed her will. Between that time and her death, which occurred in July, 1875, she exe- cuted three codicils. Each of the witnesses to the will and codicils testi- I^\sAyJTy ix its medico-legal bearings. 123 fied to the sanity and intelligence of deceased at the time of execnting- them. On the trial of the issues in the Circuit Court of St. Clair County, in April, 1877, before a jury, it "was found that the will aiul codicils were not tliose of the testator, Elizabeth M. Kiggin ; that is to say, that she was insane at the time she executed them, and they were therefore null aiul void. On appeal to the Sui)reme Court of Illinois this finding was reversed. {Uroirii. vs. liif/gi)i, 94 111. R. 560.) Alroliolism. — The will of a confirmed drunkard will stand inlaw, jiro- vided the person who made it is not in a condition to l)e so unreasonable and irrational as to be unable to exercise anything like healthy judgment. A man may be a hard drinker, and inake the wiU after a debauch, but unless its character is so absurd as to betray mental unsoundness, he cannot be reasonal)ly deemed irresponsible. In a recent case in which the Avi'iter ap])eai-ed, the testator was a man of bad habits, who drank immoderately and steadily. Evidence was produced to prove that he had done all manner of foolish things before and after the will was made, but no evidence wds brought forward to show that at the time the paper was signed the testator was in any condition to prevent him from fully knowing the nature of what he was then doing. We are to con- sider in such cases the degTce of the drunkenness, the habits and physical condition of the person. A case fell under the writer's notice two or three years ago, the testator being a nuiu of middle age, who had for months been ad- dicted to drinking, although in a periodical way. A vague history of bad temper, broken sleep, and many extravagant acts, none of which, however^ were necessarily manifestations of insanity, was testified to by the con- testants, and one physician gravely asserted that a proof of the mental perversion consisted in the irritability of the testators throat during the time he was making medicated applications to the same. He was alleged to have declared that " he could not retain anything upon his stomach " ; that '^he resorted to memoranda that he should not neglect his engage- ments " ; that " he al)used the doctor who had treated his wife during her last illness, and threatened him with violence"; that ''he complained of being homesick " : and various persons who had seen little of him testified to having observed him drunk on several occasions; that "he was extravagant, and bought large quantities of oranges," which, how- ever, were for his sick wife; and that he "talked wildly about his busi- ness." It appeared, on the other hand, that he was able to attend to his affairs for some time before his death, whi(?li was not due to alcoholism ; that when he made his will it was at a time between two of his sprees, and that thei-e was no want of sagacity or any irregularity shown in the disposition of his property. In this case, as in many others, the popidar ideas of insanity are apt to be thorouglily ventilated, and it is strange that tills kind of testimony should receive any attention whatever in courts of law. It is a very easy matter to exaggerate the disorderly be- havior of an individual who is in no sense insane. The "excitement" alluded to by interested witnesses is probably nothing nu')re than a moderate emotional exliilaration, and the busint'ss schemes which attract the wonderment of those who wish the will broken ordinarily display a mind of unusual shrewdness. The speculations nearly always turn out well, and the despondency does not rise above the dignity of an ordinary attack of the blues. In the above case the husband's devotion to his 124 ^ SYSTEM OF LEGAL MEDICIXE. dying Tvife seemed to have astonished those j)ersons "who appeared upon the side of the contestants ; and this pecnliar behavior, which was re- garded by them as e^'idenee of mental nnsoundness, consisted in such kindly offices as remo%dng her to the ^vindow, so that she might get the fresh ail", and bringing her fi^nit ; and though his exuberation of affec- tion might have been that which is so often intensified by occasional libations, it was in this case nothing nnusual. It did not appear that there was anything in the character of the vnR that indicated insanity ; l3ut that it was legally witnessed, and made at the tune when the indi- vidual was perfectly sober, and was therefore very properly admitted to l^robate. In another case of a different kind the patient had for several years indulged in large quantities of alcohol, and it was common for him to shut himself up in the room with a box of champagne, and not leave nntil he had recovered from the effects of the intoxication produced hy the dozen bottles he finished, one after the other, in rapid succession. This man, for several years before his death, drank all kinds of hquors to excess, squandered his money, giving large amounts to persons who had little or no claim upon him, and betrayed a change in character which was remarkable when contrasted viith the regularity and sobriety of pre^"ious years. Within a short time before his death he manifested symptoms of the inevitable diseases which are due to excesses of this kind, and he finally succumbed to cii'rhosis and died comatose. When suj^poi-ted in bed, and suiTOunded by those to whom he left his money, he made a will and died a few horu's afterward. This will was verj^ properly contested by his brother, and it was admitted to probate by the suiTogate, though the decision of the latter was sulisequently reversed. It is cpiite likely here that the man's mental condition was one which, €ven some time before his demise, would prevent him from pro^jerly recognizing the objects of his bounty, and render him an easy prey to designing persons ; but a will made under more outrageous circumstances it is difficult to conceive of, for he was literally in a condition of extremis when his name was signed to the document. The following is a case of alcoholism where a mental disturbance ex- isted, with delusions, which, however, were proved not to relate to the wiQ itself or those who were to be benefited : Betsy Marsh died April 7, 1876, aged sixty-five years. She was ec- centiic in di-ess and coarse in language. Her death followed a short illness — undoubtedly a disease of the brain, which gave rise to frec[uent delusions. These delusions appeared only occasionally. On the 3d of Apiil, 1876, she executed her will, and stated in answer to a question that she knew what she was doing, and later in the same day sent for a Dr. Kinch, who had drawn her will, to make some alterations in it. These alterations were never made, for the next day she was found in- toxicated in the woods, and from that time she was very ill, until she suddenly died on the 7th of April. It was testified that deceased was of sound mind at the time the \r\]l was executed ; that her delusions were only intermittent, residting from her disease, and that they consisted of presentiments of death, and did not relate to any person who might have been an object of her bounty. The "wiU was admitted in the Union County Oi-jDhans' Com-t, and on appeal to the Prerogative Com-t this action was affii-med. INSANITY IN ITS MEDICO-LEGAL BEAIilNGS. 125 In chronic alcoholism with organic brain diseases but no alleged insanity the question of responsiljility naturally arises. In most cases ■of advanced structural disease the charactter of the testator undergoes a series of changes which render him wxuik, vacillating, childish, and with- out vigorous memory. At such times it is extremely probal)lc that the person is a prey to designing relatives and suffers enfeeblement of the "will. Care should be taken not to confuse the mental impairment of old age or eccentricity with the 2)eculiarities of disposition aiid ha1)its result- ing from chronic alcoholism. {Lee vs. Scudder, 31 N. J. Equity Reports, 633.) Undue Influence. A much-abused term, which, however, has an important legal value, is what is known as undue influence. Just how much i)i'essui"e may be considered undue is of course a matter for judges and juries to decide ; jet it is a grave question whether any one is capable, without a deep in- sight into the character and mode of life of a particular individual, to ■estimate his susceptibility or powers of resistance, and to say how much he has been made to do anything against his will and at the dictation of others.* It is at best an awkward term, and should be done away with. The relation of human beings, and the doctrine of the survival of the fittest, presume the existence of individuals of varying mental attributes — some who receive suggestions more readil}^ than others, and who lack individuality, others who shirk effort, and others whose suscej)tibility to ■emotional excitement and affective influence is very great. It is there- fore of vital importance to establish the existence, if possible, of actual insanity and a prolonged departure from the former habits of life. Medical witnesses are frequently asked to express an opinion whether the patient's mental disease is not such as to make him an easy prey to ■designing friends and relatives, who may have ends of their own to gain, and through the agency of undue influence may lead or force the person to dispose of his propertj^ in a way he would not were he in full posses- sion of his faculties. It is sometimes a difficult matter to give such an opinion, for although the physician may have no doubt of the mental status of the testator, he is often bound by rules of evidence to answer a badly drawn hypothetical question which is unscientific and negative. Undue influence may be brought to bear in cases where, through disease, the individual is either unable to reason correctly, or where, to avoid opposition and worry, he injudiciously accepts the arrangements made * Johnson vs. Arnisfronr/, 97 Ala. 731. Jol\n C. Johnson died, aged seventy, in January, 1891. Will was executed September 20, 1890. In 1879 he was stricken with paralysis, his health and mind becoming impaired. In consequence his moral nature changed, and he took a woman, whom he claimed was his illegitimate daugliter, to his home and lived illicitly with her until 1880, when he became estranged from his nine children and removed to another county, where he continued to live witli the woman Tuitil he died, children being born to them. There was some evidence as to acts and peculiar conduct of deceased, quarrels with his children, his wife, and others. Tlie probate of tlie will was refused by the Probate Court, and on appeal the Supreme Court reversed the judgment on tlie ground that undue influence had not been proved, and that tliere was not sufficient ])roof that .Idhnson was insane when the will was •executed, habitual and fixed insanity not liaving been proved. 126 ^ SYSTEM OF LEGAL MEBLCLXE. by otlier peo^jle, or where Ms Trill-in ovrer is so luiieli imjiaii-pcl that he eanuot resist well-dii'eeted and decisive demands of interested plottei'^. The suspiciousness and unreasonable delusions -which the insane man harliors toward those he has always lovf d are very often played upon by interested persons, and in certain stages of delusional insanity, as well as the fii'st stage of dementia, it is possible to lead the insane indi- -sddual to do many unjust acts, under the delusion that indignities have been heaped upon him, and that insults and shghts have been offered to him. It may readily be seen how the subject of rehgious melanchoha may be made to give all his money to the church, and instances of this kind are exceedingly common, esjiecially when the testator is a woman who is tortui'ed with ideas of futui'e uni-est and punishment. The major- ity of cases where undue iirfiuence is alleged to have been exercised ai*e those where there is a history of dementia in old people. The senile dement is prone to make fooUsh and tl'i^*ial disposition of his jjroperty, and particularly is this the case when he is aicled by designing people who surround him ; and the indi^idual of this kind is very apt to be easily tiu'ued fi*om his original purpose by fresh suggestions or new influences. He is liable to imposition and unjustifiable prejudice. In paretic dementia the ^ictim is very likely to squander his prop- erty and to faU a prey to the many parasites who are eA^er ready to take advantage of Ms bonhomie and boastful good natiu-e. In a recent case the paretic, whose illusions of gi-andeiu' were of the most magnificent character, became involved in a variety of schemes demised by ingemous sharpers, and when legal proceedings were instituted it was found that he had gone so far as to buy for Ms new fiiends a cargo of bric-a-brac, and, to seciu-e a place for the sale of the same, he had bought up the stock of the occupant of the store, siiending $30,000. so that his fi-iends might take immediate jnossession. In patients suffering fi'om the fii'st stages of the disease it may readily be seen how any one. by judicious flattery and accpiiescence in the startling projects and ideas of the indi- ^ddual, may wheedle him into parting with property. In other forms of organic insamty a condition of mental feebleness akin to dementia is manifested by ii-resolution, ii-ritability, or intellectual torpor. It will frecpiently be found that disease of the cerebral vessels, especially on the left side of the brain, is very apt to be followed, if at all extensive, by degeneration of the mental faculties ; and if such degen- eration has au early fatal ending, and a biased and mijust will is made, even though there can be brought forward very few instances of mental ii-regularity, we should still question the abihty of the patient to with- stand the arguments of interested fi'iends. Sof temng is so common after accidents of the kind mentioned above, and is so frequently symptom- atized hj loss of memory, indecision, and childishness, that intellectual competencA^ should always be questioned. On October 12, 1872, Mrs. Elizabeth Greenwood, tlien sixty-two years old, executed her wiU. She died August 9, 1875, leading an estate worth $26,000. By the terms of her AA-ill she bequeathed to two of her children, Eliza Smith and William Greenwood (the contestants), $100 each, and the residue of her estate to Olive Xewsome, a granddaughter, and Mrs. Mary Cline, her remaining child. The will was contested on the gi-ound that the testator was of weak mind at the time it was executed, and un- duly influenced. It was not claimed, however, that she was incapable of I^'SJ^'ITY IN ITS MEDICO-LEGAL BEARINGS. 127 oxccnitiiifjj tlic will, Ijiit that she was lahoriii^' uiuhT a iMusioii with regfird to contestants, l)roiij;ht ahout by the undue influence exercised u})on her weak and ini})aired mind by Mrs. (line and Mrs. Xewsojne. Upon the trial of tlie issues in the County Court the will was rejected, the court holding- that while deceased had testamentary capacity, the will was executed under undue infiuenee. On appeal to the Circuit Court this judgment was reversed, and contestants then ai)pealed to the Supreme Court, wlio I'eversed the judgment of the Circuit Court and rejected the will, on the same ground taken l)y tlu; County Court, and also sustained the <'laim of contestants that deceased was lal)oring under a delusion regarding them at the time she executed the will. The evidence, which is voluminous, shows that deceased had a severe attack of paralysis in 18G(), from the effects of which she never recovered ; that her memory became defective; she could not tell who was working for her; would lease a piece of land and forget it next day ; would ask the same question repeatedly. Two medical doctors who had known deceased testified that she was very despondent ; was different from the majority of people ; at times exhibited mental obliquity ; her mental powers were impaired. Others testified that her eyes had a dead expression ; she sometimes acted like an intoxicated person ; in 1872 she was peculiar in her conversation ; would stop short while making a remark, and fail to finish it; was absent-minded ; while ill she imitated, with empty hands, the action of a person breaking a piece of quartz and examining for gold ; she very readily gave up her opinions, and would side with anybody who disputed them ; that while going from Salem to Howell's Prairie alone, she became turned around in the road and was coming back to Salem without know- ing it ; that slie did not appear cheerful, or laugh ; paid no attention to her housework ; she was frequently told that her mind was not right ; that on the day slie executed her will she submitted herself to a short examination by two doctors, from whom she obtained a certificate of her sound mind and competency to make a will ; that Mrs. Cline by means of a pretended communication from her deceased husband, obtained through a spiritual medium, stating that her son William was a rough character and would squander her property, and that she should get it all out of his hands, produced a delusion in her mind regarding the character of her son. There was some evidence on behalf of proponents regarding tlie sanity of deceased, but as this was admitted it is not neces- sary to give a rhmne of the evidence. The will was rejected on the ground of undue influence — that it was the offspring of a delusion re- garding the contestants. {Greenwood vs. Cline, 7 Oregon Reports, 17.) Hypnoti.sm. — Since the revival of interest in hypnotic suggestion and the attention paid to the subject by the newspapers, the claim has been frequently advanced in courts of law that certain unsatisfactory wills were made by decedents who were unduly influenced by hypnotism. After much research I am unal)le to find a single authenticated ease of the kind, but, on the other hand, rather a great deal that shows how ignorance and ])rejudice, flourish, as they did in what were supposed to be less enlightened ages. As a rule no mention is made of hj^Dnotic sug- gestion until after the will is found. That a person can be made to perform an unjust act through the suggestion of others is of course possible ; but as a rule the suggestion must be an abstract one, that is, provided the subject is possessed of ordinary mental health and normal 128 A SYSTEM OF LEGAL MEDICINE. independence of will. It is quite possible that while actual hypnotic un- consciousness is not produced, an old person may make an unjust will thi-ough the constant suggestion of an idea by interested persons. Such acts are common ;\-ith aged people who fall into the hands of shai-pers, cure-alls, or disreputable exhorters. The experiments of investigators shoidd certainly go to show that it is impossible or extremely difiacult to make hjqDnotized subjects do things that are naturally repugnant to them. The suggestion of disrobing was made to a number of women, half of whom were of known immoral character. The virtuous women would not do so, but the others, -N^-ithout hesitation, took off their things. Possibly a determined induction of hj^Duotism might throw a testator into an iiTesj)onsible condition, when his Ttih would be subservient to that of another ; but he would be very likely afterward to question and regret the nature of his act. It may be said that insane people are with difficulty hj^^notized ; so if insanity is alleged as a contributory part of the incapacity it -odll be important to determine the extent of attention possible. Suicide. The validity of the wiU of a suicide is sometimes questioned by reason of alleged uisanitj^ The last hom-s of most suicides are, as a rule, marked by some expression which will enable one to determine the probable mental state. De Boismont, Winslow, and others have collected an immense number of wi'itten expressions of suicides, and the former has gotten together over three hundred and twenty letters which show the most diverse forms of mental tortm-e. Eighty-five T^-ills were col- lected by this observer, the greater number shoA^'ing clear and intelli- gent disposing power; and it does not follow that because a suicide has X)robably sho^vn peculiarities of conduct before his death he has lost the power to discriminate in the matter of choosing the objects of his bounty. On the other hand, there are many wills made by suicides that are irrational and absurd — some of which contain clearly insane directions in regard to the disposal of the body, the personal effects, etc. These should always be received ^ith great caution. CONTRACTS. The plea that a contract has been entered into by a person when in an irresponsible state is often urged. In contracts that are disputed because of the alleged insanit}^ of one of the parties it is necessar}- to examine not ovlj the individual, but the instrument. If it is discovered, in addition to the insanity of the contracting party, that the bargain is clearly disadvantageous to him, the question of fraud and imposition is raised. It sometimes happens, on the other hand, that the question of mental unsoundness is agitated when it is the aim of a j^erson to shirk a responsibihty.* In a recent case in which the* ATOter appeared, the ques- * Lillji vs. Waogoner, 27 HI. 395. Bill to set aside conveyance of real estate, by George Waggoner, conservator of Elisha Waggoner. In ]S51 Elislia Waggoner con- veyed real estate to A. Lilly. In 1858 an incjuest declared Elisha insane, and George was apijointed eonsei-A^ator of his estate. It was alleged that " for a long period pre- vious to the inquest " in 1858 Elisha was insane, but there was no i)ositive proof. Oil INSANITY IX ITS M KhlCO-LEGAL JiEAUlMJS. 129 tioii of Tnolancholia was iirroved, is a barrier to the claims of those who seek to avoid obligations incurred with persons of weak mind. TJie JJegree of Unsoundness. — The degi-ee of unsoundness necessary ta invahdate a eonti-act as fixed hy the law is imcertain and indefinite. The requirement of sufficient intelligence upon the part of the contracting Xjarty to know the nature of his act, however, no matter what may be the foi-m of mental disease, is aU that is demanded. He may be an im- becile or idiot, but unless the latter condition be an extreme one he does not escape the obligation iucurred. His estate is liable for debts con- tracted to supxjly his immediate needs, and he or his administrator may be sued. He is also liable for debts contracted during his lucid inter- vals, but no infeiTcd insanity, such as is ui'ged in the fact of his having been in an asylimi and discharged, is sufficient proof of his recoveiy. (Wharton and Stille.j The contracts made by a lunatic dui'ing life are void; but the incapacity must be proved, for the obvious reason that there may have been only a partial incapacity during life.t In such cases the administrator may be held liable. There are decisions which have held that any conti-acts executed by lunatics are in themselves void.t * Jenkins vs. Morris, L. K. 14 Ch. D. 674 ; Mitchell vs. Kingman, 5 Picli. 431 ; etc. t Ducker vs. JVIdtson, 112 X. C. 44. This was an action brought against "Wliitson as administrator of W. R. Murray, by heirs of said Murray, to whom he in his lifetime had executed notes, with a -n-ritten agreement that they were to be paid out of his estate after his death. The defense was that at tlie time the notes were executed he was weak in body and mind, and not mentally capable of making a contract. There was evidence that he had made other contracts, had been justice of the peace and postmaster, and attended to his duties. There was also much other testimony as to- his mental capacity, the details of which are not stated in the report. Judgment for plaintiff affirmed. X Curtis vs. BrowneU, 42 Mich. 165. This was a bill to set aside a mortgage, on. JySA^UTY IX ITS MICDKJO-LlidAL JlJJJJnXdS. 131 Marriage and Insanity. It sometimes happens that an attemi)t is made to invaUdate a mar- riage^ one of the contracting- parties being- alh^ged insane. It may be that the person in whose aid the power of the courts may be exercised is at the tiine of marriage a d(!clared hmatic, in which case all that is required is a sliowing of the linding- of a previous commission. More often the contracting party is one of weak mind, who has been entrapped ))y designing persons. The same influences that may have been Ijrought into play to make a man link himself with some prostitute or adventu- ress nuiy be brought to bear to make him an earnest defendant when his family bring action to set aside the marriage. In such a case he is ami)ly provided with friends and advice, who supply the brains he un- fortunately does not possess. It will be readily seen that the sexual perversion inseparable from various forms of insanity may lead to a union perhaps with some one far beneath him, and in the other sex the influence of nymphomania leads to impulsive acts which the per- son, who perhaps is an hysterical girl, does not stop to consider. The -celebrated English case of Miss Bagster is an example of this kind. " Miss Bagster was proved by the evidence to be a frivolous and weak- minded girl, whose education had been much neglected. She was a lady of fortune, and she ran away with and was married to a Mr. Newton. An application was made by her family to dissolve the marriage on the ground that she was of unsound mind. Among other facts urged before the commission as proof of the allegation, it was mentioned that she was occasionally violent and self-willed, that she was passionate as a child, and that even in maturer years she had little or no self-control ; that she was ignorant of aritlimetic, and therefore incapable of taking care of her propert}^ ; that she had some erotic tendencies, which were evinced by her want of womanly delicacy, and by her having engaged herseK, the gi'oimd of insanity of the mortgagor at the time of its execution, to secure pay- ment for a set of mill machinery. The evidence showed that he had been engaged in business all his life, and managed a farm and other interests. He had always been visionary and speculative ; had various absurd schemes ; planned great improvements in his neighborhood ; had periods of exaltation, and of depression, when he feared des- titution ; planned to manufacture pianos and furniture ; to build a town on an adja- cent farm, with a church and school ; claimed to have invented an excavating machine ; talked of setting up a woodyard in his village, and atten^pted to make contracts for wood; and claimed he had $80,000 at his command. The mortgage was made in No- vember, 1875. In the following spring he committed suicide under peculiar circum- stances. At times when he indulged in his extravagant talk and actions he was pale and haggard. Judgment for plaintiff affirmed. Ldiieaster Coinifi/ Jicnik vs. Moore, 78 Pa. St. 407. On December 30, 1871, George H. Moore, a man of jiroperty, about fifty-four years of a^ge, called at plaintiff's bank, and obtained the discount of two notes signed by him, amounting to $1000, the money being placed to his credit and afterward cheeked out by him. Tins money lie applied to the pajnnent of a debt. There was nothing in his acti(uis to warn the officers of the bank as to his mental condition. On June 5, 1872, de hoiolico proceedings were in- stituted, and on Augtist 10, 1872, inquisition returned that Moore was a lunatic, and had been for three years past. In this action to recovei- on the notes, Moore's insanity at tlie time the notes were executed was set up as a defense. There was no evidence of Moore's insanity bej'ond the record of the proceedings in hmacy and neighborhood reports, which latter it was held were not sufficient to constitute notice to the V)ank. Verdict for defendant, which was reversed, the Supreme Coiu-t holding that '-the law 232 ^ SYST£Ar OF LEGAL MEDICLXE. ■witli a view to marriage, to several individuals. Ou her examination before the commissioners her answers were intelligent, and her conduct in no way different from that of ordinary individuals. Seven medical witnesses were summoned to sujDport the commission, and each of them deposed that she was of unsound mind. The commissioners, however, had recourse to Drs. Morrison and Haslam, who visited her, and who came to the conclusion that she was neither imbecile nor idiotic, and that her inability to manage her affairs arose from ignorance. She was- aware of her deficiencies, and deplored her ignorance of arithmetic, and explained it ou the ground that her grandfather had been too ready to send excuses for idleness when she was at school. Her conversation greatly impressed Drs. Haslam and Morrison with a belief in her sanity. The juiw, iDy a majority of twenty to two, retm-ned a verdict that Miss- Bagster had been of unsound mind since November, 1830, and the mar- riage was consequently dissolved." Breach of Promise and Insanity. Breach-of -promise cases are often defended upon the plea of insanity and irresponsibility. In the case of Harford vs. Singleton, it was claimed that the defendant's softening of the brain and insanity were cogent rea- sons for his non-fulfillment of the marriage contract, which plea, how- ever, was unsuccessful. This action was defended on the ground that at the time defendant had promised marriage he was advanced in life, viz., sixty years of age ; and that before a reasonable time had elapsed from the request to marry, namely, in May, 1855, he was, by a " visitation of God," attacked by a 'fit of apoplexy-, since which time he was in an infirm state and afflicted with softening of the brain, in consequence of which he could not perform his promise without puttuig his life in great j^eril and hastening his death. Evidence was called, on the part of the plaint- iff, to prove the engagement and to shoAv that no apparent impah-ment of health or vigor remained after recovery from the attack. It was stated by defendant's counsel, Mr. BaU, that in 1849 he had suffered from di-opsy aiid disease of the kidneys : that in 1852 he had an attack of apoplexy and congestion of the brain ; diu'ing the inter^'al from that tune until May last" he had promised to marry the plaintiff ; Imt that in the latter month he was afflicted with another attack of apoplexy, and was now suffering from paralysis and softening of the brain. The defense then called several medical men who had attended the defendant. They tes- tified that he had had apoplexy and was paraMic, was suffering from is well settled that persons who are not sni juris, and have no general capacity to- contract debts, are nevertheless liable for their torts, and may bind themselves for necessaries." The bank having acted in good faith and without notice, the estate of Moore was liable. Mutual Life Lis Co. vs. Hunt, 79 N.Y. 541. Action for foreclosure of a mortgage- executed by defendant April 23, 1870, for $40U0 money loaned, payable September 1, 1871. Interest was paid to March, 1871, but in September, 1871, default was made. In December, 1871, defendant was adjudged a lunatic. At Special Term judgment was gi'anted for plaintiffs, wliich was affirmed at General Term (14 Hun, 169). The Court of Appeals sustained tlie judgment, holding that the fact that defendant was declared insane after tlie mortgage was executed cannot prevent plaintiffs from enforc- ing the contract, which was made in good faith by them, and without notice or fraud on their part. IXSAXITV IX ITS MEDICO-LEG JL IJEAIilXGS. 133 loss <»f im'morv and other mental symptoms, and that he was liable to another atta<'k, and tliat anj' exeitement would increase the tendency to sncli attaek, but would not say that he mig-ht not marry without imperil- ing his life. The jury rt'turn<'d a verdict for the i)laintiff of £300 damages and costs. The ground of this verdict, it is said, was that the jury con- sidered that an unreasonal^le time had elapsed between the date of the promise of marriage and the date of the last attaek of apoplexy. Divorce, Annulment, Legitimacy, and Insanity. The plea of insanity is sometimes nrged as a gi'ound of divorce, and in one case which occurs to the writer the husband of an insane woman, whose disease developed after marriage, brought suit for separation. In ordinary cases such inhumanity, in disregarding the existence of the af- fection as an unfortunate calamity for which the jjatient is no more re- sponsible than she wonld be for smallpox or typhoid fever, rarel}' finds favor in the eyes of the law; but it can be realized that in instances when insanity has existed before marriage, and when the husband or Avife has been kept in ignorance of the fact b}' the patient, or by his or her parents or near relatives, a delicate legal point may arise.* The attitude of the German coiu-ts regarding this question is most moderate. A late decision of the Beichsgericht (vol. xx\di., p. 158) con- cerns a petition for the annulment of a marriage because the husband had an erroneous opinion in regard to the sanity of his wife when mar- rying her. Evidence was brought to show that the defendant had a he- reditary predisj^osition and had been temporarily insane before as well as after her marriage. • The plaintiff had married the defendant in 1886, and after the birth of a healthy child in 1887 he left her, and in 1889 brought an action for divorce, alleging that his wife was the subject of liereditaiy insanity, and that she had before marriage and afterward shown signs of what he claimed to be incurable insanity, and that he was unaware of this fact when he married her. The defendant only admitted that she had been temporarily deranged after the bii'th of her child, such insanity being puerperal, and, moreover, that the plaintiff * Banker vs. Banlcr, 63 X. Y. 409. The defendant, Ellen M. Banker, and John Banker were married March S, 1869. In Febrnary, 1869, proceedings de lunatico in- qiiircudo were instituted, and on Marcli 10th, two days after the marriage, it was found that John Banker was a lunatic, and had been for six months previous. Mrs. Banker liad notice of these proceedings. John Banker subsequently died, and David A. Banker, as heir at law, brought this action for annulment of the marriage, on the ground that John was a lunatic at the time the marriage was contracted. The jury found that .John Banker was not insane on March 8, 1869 ; that he had lucid intervals, and affirmed his marriage after that date; that he was not insane at the time of his death ; and that ^Irs. Banker had notice of the lunacy proceedings. Judgment was then entered dismissing tlie complaint, which the General Term affirmed. The Coiu't of Appeals also affirmed the judgment, "the inquisition is conclusive against subse- quent acts and dealings, and presumptive against prior ones," irrespective of notice. Ilairdon vs. Rawdon, 28 Ala. 565. This was a bill filed by ilrs. Elizabeth Eawdou for a divorce from her husband, Isaac Kawdon. It was alleged and proved that they were married; tliat Isaac was insane at the time of marriage, and for some time after- ward, unknown to his wife. His insanity was caused by bi-ain-fever. About the time of the marriage he had a lucid interval, but after the marriage she began to notice Iiis strange conduct, althougli he was considered an intelligent man by many. About six years after marriage he developed religious uiauia, and his lucid intervals ceased en- 134 A SYSTEM OF LEGAL MEDICIXE. had lieen aware of her state of mind from lier very yontli. The fact that the brother of the defendant had j^assed two years in a State kma- tic asylum in 1882 and had been discharged imcured was admitted. The court decided against the plaintiff on the following grounds : That after its investigation, as well as upon the medical rej^ort'of the director of the asylum, it was clear that the defendant, at the time of the set- tlement of her maiTiage, was not in a state of chronic mental disease, nor was she then suffering from even a temporary attack of mental dis- turbance. It was determined that she was hereditarily afflicted and was thereby exposed to the danger of mental disease, and' that twice in her life, once before her marriage, at the occasion of the death of her sister, and again about six months after her accouchement, she had suffered from attacks of acute mental distm-bance in the form of passive melan- choha. It was the opinion of the coui-t that no one had ever gone so far as to decide that a temporary disturbance of mind which was un- known to the other party, occmiing before maniage, even if tliis disturb- ance reapi)eared after maniage, could serve as a cause for annulment, and, moreover, he was unaware of any precedent for the annulment of a marriage because one of the contracting parties was hereditarily aflicted with a predisi^osition, and a temporary derangement had appeared after the consummation of maniage, such disorder being provoked by suffi- cient causes. In the case under consideration the defendant recovered completely each time after a few weeks. It was also held that the de- fendant had no reason or cause, nor was she obliged in any way, to com- municate to the plaiutiff the fact or natm-e of her previous iUness. It has also been held by the German com-ts that an innocently ac- quired insanity of husband or wife does not constitute sufficient ground for divorce. {ITjid., vol. vii., p. 154.) The com-ts even go so far as to protect the insane defendant whose disease prevents the consummation of cer- tain customary habits of matrimony (sexual iutercoiu'se, etc.). The AU- germine Protestardisdte Kirchen-Eecht (General Protestant Church Law) considers wedlock as a communion standing above a common agi'eement and bindiag the whole personahty of the contracting parties in ah situa- tirelr. During Ms paroxysms lie frequently attempted to kill his negi-oes, and actually did kill their only child, erected a scaffold, and bm-ned the body, saying that he " offered his son a sacrifice to God, as Abraham had offered his son Isaac " ; and he had since been confined in an asylum. The bill -was dismissed on the gi'ound that the marriage was contracted during a lucid interval ; and on appeal the Supreme Court affirmed this judgment on the gi'ounds named above. The com-t also laid stress on the facts that the marriage was contracted in 1826, in 1836 Eawdon developed insanity, and Mrs. Kawdon did not file her bill imtil 1854. State ex rel Setzer vs. Setter, 97 N. C. 252. In August, 1859, Eeuben Setzer and Sophronia Morcus were married, and lived together until 1862, when he enlisted in the Confederate army and was killed. This action was brought by the State on the relation of Jacob C. Setzer, the only child born of the marriage, against the defend- ant, who administered the estate of Reuben Setzer on his bond for a share of the personal e.state. The defense was that Eeuben had been an imbecile fi-om his youth up, and was insane at the time the marriage was contracted. A jury declared that the inte.state did not have mental capacity to contract the mamage, and judgment was rendered for defendant, which on appeal was reversed by the Supreme Court, the court holding that the question of the validity of a mamage could not be considered in an action by children of the marriage claiming as next of kin, neither of the parties to the marriage being before the court, and that " the present verdict cannot take from the relator any of his rights as a son of the intestate to a share in the latter's estate, nor render his birth illegitimate." JXSAmTY IX ITS MEDICO-LEGAL nEJUlXGS. 135 tions and possibilities of life until one or the other of the parties be- <,'onics by his own fuult unworthy of the other. Unconsciously ac(|uire(l madness, if developed after inarriag'e, is therefore no ground for divorce. The Gernuiu law [Alh/ciiwiiics Ijoidrerht, sec. G982), however, holds that rage, insane fury, and dangerous madness justify a divorce when such a derangement has lasted for more than a year and there is no possible lK)pe of recovery. The famous Mordaunt Divorce Case, in which the Prince of Wales fig- ured, is one in which j^uerjDeral insanity was urged as the basis of irrespon- sibility. Lady Mordaunt, after her confinement, admitted that she had com- mitted adultery before the birth of her child, and the evidence substanti- ating her story was seemingly ver}- strong, for entries in her diary a year before recorded the visits of a nobleman at an hour of the iiiglit inconsist- ent with the strictest propriety. This occurred two hundred and eighty days before the birth of her child. It appeared from the testimony of servants and others that there had been no signs of anything pecidiar in the conduct of Lady Mordaunt either before or after her delivery, and this was in contradiction of those friends of the patient herself who asserted that her confession was the result of a delusion ; for not only had the wife admitted improper relations "s^dth other men, but swore that the child was not her husl^and's. The patient was delivered of her child on the 28th of February, 1869, and a week or two later made her extraordinary admission. The physicians called by the plaintiff were inclined to think that she was not insane, and that there was nothing in her conduct inconsistent with feigning. The reasons assigned as evidences of her insanity were of the most extraordinary^ description, but they were met with much that was contradictory. It was shown that her habits had become filthy, that she destroj^ed her clothing and was unclean in her habits ; and in 1870 she was demented and could not comprehend communications that were made to her. The jury and the judge took this latter view of the case, aud it was decided that as early as the 30th of April the respondent had not sufficient capacity to bring the suit, and had been unfit ever since. The charge of the judge to the jury was, that he did not ask them to say whether Lady Mordaunt was sane or insane, but simply to decide '' whether she was or not in such a state of mental disorder as to jn-event her giving instructions." The ease was afterward appealed and tried upon its merits, the matter of insanity being left out of the question, the defendant being considered guilty of adidtery, and the divorce was granted. Woodman and Tidy, in com- menting upon this case, say : '' It is thus seen that insanity is no bar to a decree of divorce — a principle which seems to us far from being a safe one. In a case of miu'der the evidence of other persons or circumstantial evidence may be sufficient. In the relations of husband and wife it seems hard to punish the wife while she is unable to defend herself. At all ■events, if the principle be admitted, it seems unjust that a poor laborer should have to pay toward the support of an insane "wife in Colney Hatch or Hanwell, and l)e liable to a prosecution for bignmy if he mar- ries again, while the wealthy baronet escapes almost scot-free and may marry again if he choose." Marriages contracted in exfre)nis are usually very apt to be dissolved l)v courts of law. Tidy refers to the case of Rochefort, who was married to his former mistress on her death-bed, he being taken from prison for 136 ^ SYSTJEM OF LEGAL MEDICINE., the purpose. It appeared that the woman was iu her right mind, and consequently the marriage was held to be valid. But where one of the parties is overawed, or there is any evidence of mental perversion, the legality of the contract is properly questioned. A case showing that the alleged insanity must be that which iu itself wiU interfere with a proper understanding of the marriage contract is the following. In it " kleptomania " was urged as a ground for divorce. Lewis vs. Leivis, 44 Minn. 124. The parties to this action were mar- ried in 1882, At the time the defendant was insane, but this fact was. concealed from plaintiff until 1888. The plaintiff brought suit to annul the marriage on the ground of fraud in the concealment of defendant'^ insanity, and also that defendant was not competent to enter into a mar- riage contract. The insanity alleged was " a morbid propensity on the part of the wife to steal, commonly denominated ' kleptomania.' " Judg- ment for defendant, which was affirmed by the Supreme Coui"t, on the ground that the insanity proved did not show that defendant was in- capable of understanding the marriage contract, and that the conceal- ment practiced was not sufficient to justify the court in annulhng the marriage. The plea of non-support by reason of insanity as a ground for divorce has not found favor with the conrts.* In the case of BaAer vs. Baker, 82 Indiana Reports, 146, it was shown that plaintiff and defendant were married in 1867. In 1874 defendant became insane, and was committed to an asylum, where he has since remained. Plaintiff instituted this suit for a divorce on the ground that defendant failed to support her. The Supreme Court on appeal held that this did not constitute sufficient ground for divorce; that the statute providing for divorce where the husband fails to support his wife does not apj)ly when such failure is caused by mental or ph3;^sical disease. Another issue was raised in the case of Gevliold vs. TFyss, 12 North- western Reporter, 800. The plaintiff and defendant were married in " September or October, 1867." A few days thereafter plaintiff learned of defendant's insauitj^, but continued to li-^^e with her until September, 1881, when a decree of separation was made. He now sues for her sup- port during the tune they lived together. The Supreme Court of Ne- braska held that as plaintiff knew of defendant's insanity, but continued to live "with her, he was obliged to support her. The existence of epileptic insanity or epilepsy may form the basis of legal proceedings, and the existence of epilepsy which has been concealed by the subject from the other contracting party may arise in proceedings for divorce. A pertinent case is related by Trousseau of a lady who was aroused at night by the restlessness of her husband, who violently at- tacked her, and she was obliged to call for assistance. This occurred again, and by means of a light she was enabled to see the patient in the "* Bell vs. Bennett, 73 Ga. 784. This was an action by Mrs. Bennett against the administrator of Jesse Bennett for a year's support, Mrs. Bennett chiiming to be the ■wife of Jesse. Tlie defense was that at the time of the pretended marriage Jesse was insane, and that slie lived with him but a short time and then eloped with another man, with whom she lived for twelve years ; biit the Trial Court refused to receive e^adenee in support of these facts, and ordered judgment for Mrs. Bennett. On appeal the Su- preme Court held that Bennett was insane at the time of the marriage, which w^as,, therefore, void, and remained void till his death, and reversed the judgment. lySJNITY IX IIS MEDICO-LEGAL BEAIilXGS. 137 midst of a severe epileptic attack, and he would again have done violence if not restrained. In this ease the patient had but an indistinct idea afterward of his condition, but he admitted having had other attacks previous to his marriage, of a vertiginous character. Hence it seems to me there should be no reasonable excuse for denying a divorce, especially if the patient was cognizant of liis previous disease and neglected to communicate his knowledge to his wife. BANKRUPTCY. A person who in the eyes of the law is non compos mentis cannot com- mit an act of bankruptcy while his disability lasts, but if he has done so previous to his lunacy, he may be made the subject of a commission of bankruptcy.* (Ordronaux.) He cannot be arrested, and during the continuance of his insanity the time cannot be regarded as a part of that limited for certain motions to set aside a judgment. THE INSANE AS WITNESSES. The testimony of a lunatic whose incapacity has been determined is of course incompetent, and he will not be permitted to testify until after his restoration to mental health. The time of existence of his "civil death " is to be determined before any testimony shall be received. " Look- ing at the condition of the mental faculties during the prevalence of in- sanity, the disturbance of their equipoise, the emotional excitability present, and the underlying raptus mamacus touching every faculty at some point ; rememljering also that every human being is steeped in his own temperament, wears the liver}^ of his ordinary mental states, and exhibits in his unguarded acts the complexion of his predominant moral feelings — we are forced to the conclusion that, even outside of the sphere of delirium and incoherence, the statements of one who is insane or has been profoundly so, but is now recovered, need to be scrutinized from " Stock. N. C. 38. In re Murphy, 10 National Bankruptcy Reg. 48. A petition in bankruptcy was filed against Alonzo Murphy by his creditors, and on his failiu*e to answer he was ad- juged a bankrupt by default, and his property was turned over to the assignee. Be- fore distribution had been made Murphy appeared with an application alleging that he was iio)i contpos mentis at the time the debts were created and the bankruptcy pro- ceedings instituted, and the court (United States District Court, Tennessee) opened the default. Subsequently a jiu-y rendered a verdict of insanity, and the assignee was ordered to return the property to Murphy. Ih re Weitzel, 7 Bisscll, 289. This was an involuntary petition in bankruptcy. Insanity of bankrupt was pleaded as a defense. On demurrer to the answer the United States District Court for the Western District of Wisconsin decided : First, That a lunatic can be adjudged a bankrupt against the consent of his guardian. Second, Tliat an insane person cannot commit an act of bankruptcy. Ill re Marvin, 1 Dillon, 178. William L. ^[arvin, a merchant, siispended payment on January -i, 1871, and did not thereafter resume, and his property was levied on shortly afterward. In February this petition in bankruj-ttcy was filed against Mar- vin, who, by his guardian, answered that on January 30. 1871. he had been adjudged insane, and that he was insane at the time the acts of bankruptcy were committed. Tlie District Court overruled a demurrer to the answer, aiul on appeal tlu^ Circuit Court affirmed the judgment, holding that a person who is "wholly incapable" can- not commit an act of bankruptcy. 138 ^ SYSTEM OF LEGAL MEDICINE. a standpoint not so mncli of veracity as of intellectual competency." (Ordronanx.) Authentic instances of a lunatic testifjdng are rare. In the case of Begina vs. Hill, 2 Denis, C. C, 254, 1851, a lunatic, Donnelly, was permitted to testify in regard to an assault after having been ex- amined as to his competency. Although exceptions were taken, the ver- dict was sustained. As to matters of bare fact thei-e can be no doubt that an insane per- son is often able to testify intelligently, but it is necessan' to ascertain if a delusion or delusions exist, or if the person called entertains insane prejudice. In matters where the slightest question of opinion or the formation of an opinion arises, the testimony of such a person should be accepted with, the greatest care, especially in cases where emotional states exist. Some authors hold that a person who has been insane and recovered should be permitted to testify to facts occurring during his insanity, provided the facts are " objectively demonstrable," and he knows the nature of an oath, and the court is satisfied with his degree of under- standing; but that "a personal and self -regarding incident occurring during a period of insanity, and testified to by its subject either while still insane or when recovered from that state, should not be treated per se as an evidential fact." On the whole his testimony should be cor- roborated, THE COMMITMENT OF THE INSANE. The laws governing the commitment of the insane vary greatly in detail. (See Appendix.) In some States the affidavit of one physician is sufficient, in others two, while in others the alleged lunatic is to be brought before a jury, who pass upon his case. The appointment of a commission is a more elaborate and satisfactory way of determining the incapacity of a person, if he be a lunatic or habitual drunkard ; and the duty of such a body is to fix his status so far as his being a free agent is concerned, to inquire whether or not he is able to manage his property, and, if necessary, to appoint a guardian of his estate and person. Upon the presentation of a petition a judge of a court of record usually appoints three persons, one of whom is a physician, and another a lawyer, and these conduct a hearing either in the presence of a sheriff's jury (New York) or a specially impaneled jury. Upon the finding of this body that the person is insane and unable to manage his property or himself, a proper guardian or guardians are appointed ; sometimes one for the care of the property, and another for the person. If the patient demurs at the finding he has the right to a traverse, which is granted if the appointing judge deems it wise, in view of his condition — that is, whether his will is not entirely gone or there is a possible doubt — when an appeal is permitted to a court and jury, who decide whether or not his denial of the charge of insanit}^ is well founded. The fullest inquiry should be made in such cases, although reform is needed in the adnussion of testimony. In its efforts to protect the indi- vidual, justice sometimes topples backward ; and in its granting of lati- tude in the application of legal rules, hearsay and prejudiced testimony are admitted, some of which, even if subsequently discarded, infiuences the mind of the too sj-mpathetic jurymaii. Great care should be taken in giving or preparing testimou}-, for it often happens that the reasons JXS jy J TY ly ITS MEDlCU-LEdAL nEARlMJS. I39 assigned for the alleged iu.siuiity are of the most flimsy character, and may be trumi)ed \\\) by designing relatives and too readily accepted by careless medical men. It shonld be asc(?rtained whether the individual has been insanelu extravagant ; or whether he has been swindled repeat- edly or drawn into absm-d spi^culations. One old lady whom I examined invested two thirds of her small fortune in bogus mining companies within a few months, and spent considerable suras of money in the most foolish ways, while before this time she was penurious and economical. It is often necessary to decide the question whether a person of weak mind shoidd be detained in an asylum or placed in charge of a guardian and permitted to live outside ; and the courts are exceedingly lenient in such matters and justly so, being especially careful in regard to the pos- sible abridgment of personal liberty. The Dickie Case was one of this kind, and though the medical men who examined the patient considered her an insane person, their view of the case was disregarded, and the late Judge Brady ordered Miss Dickie's discharge, but appointed a guardian. " Miss Dickie was sent to Bloomingdale on the certificates of Dr. White, and of Dr. Alfred C. Post. She was accepted as a lunatic by Dr. Tilden Brown, and retained as such by Drs. Nicholl and McDonald, with the implied consent of her aged and imbecile father's physician and guardian, Dr. Rauney. '■'■ On the afternoon of January 16, 1878, Miss Dickie was visited by a physician, who gave her his name and address, and told her he was a physician who had come to see her. She was found to be diminutive in size, lame, and api^arently deformed, hard of hearing, and with speech very indistinct and imperfect, from a very wretched condition of her gums, teeth, and mouth. The latter, it was supposed, could easily have been relieved by careful rinsing and washing of the mouth. There were other signs of carelessness of person and dress which were not ^dsible in the persons of the matron, attendants, and other patients who were casually observed. " In a little while she was conversing quite freely about bad treat- ment she had received from her father, who, she said, used to puU her hair and otherwise maltreat her ; of deceit on the part of her brother and sisters ; of bad treatment on the part of Dr. Brown and others. She also complained of the food she received ; that they sometimes had onions for dinner, and that these were served especially to annoy her. She stated that an effort was being made, with her consent and that of her family, to remove her from the asylum, and expressed a preference to live in the city rather than in the (jountry, with some slight hint which suggested that she did not like green things, but desired to visit shops, go ro her own church, give money to it, and live by herself. She volunteered to say that she read the l:imi and the Ohserver, and showed copies of them ; that she had a great impulse to improve her mind ; quoted some simple little nuixims at times, especially about not talking too much, when she was monoi)olizing almost the whole conversation. As she occasionally quoted Scripture, she was asked if she had a Bible ; it was then noticed that she seemed to keep almost all her property under lock and key, but she quickly produced her Bible from a locked drawer, and it was found not only filled with pencil-marks from Genesis to Revelation, but many pages were folded in the most curious and complicated ways, as if to 140 ^ SYSTEM OF LEGAL MEDICLyE. mark special j^assages of great import to herself : but her \'isitor was siu'prised on unfolding these ciuionsly donbled-up pages to find no pencil-marks Avhatever upon some of them, and she avoided answering why she thus pointedly singled out particular pages. It is bareh^ pos- sible that those were pages which she did not wish to read, but nothing could be detected strikingh^ peculiar in the contents of those pages upon a short examination. " Her fii'st visitor had been alone with her for half an hour or more when another physician came into the room, and was introduced by name and title as a second medical man who had come to see her. She imme- diately went on conversing with hun. His attention was attracted by hearing her tell her second visitor that there was a language of food as well as of flowers, and when asked for an illustration stated that coffee was brown, brown was a Quaker color, a Quaker was a Friend, and that hence coffee meant friendship ; that if one j^erson gave another a cup of coffee, it was a sign of friendsliip, and if milk, which was white, was put into it, it was a sign of j)ure fi'iendship, and the addition of sugar made it an indication of sweet friendship — in short, that coffee with milk and sugar in it was indicative of pm-e, sweet fi-iendship. Then she vohmteered to say that bread represented a fiiend ; that a big piece of bread was a sign of a large friend ; that butter signified refinement, and bread and butter a refined friend. She then quickly said that cabbage was white on the inside, and that signified pm-ity, and gTeen on the outside ; but no C[uestioning could make her say what the green meant. She continued to say if one cut up the inside of cabbage and put it on a little plate, it would indicate puiity and something else which she would not disclose, possibly because it had reference to the gi'een color. " Repeatedly, while tliis conversation was going on. her visitors were warned not to speak loud, as persons were watching all the time, up- stairs and downstaii-s, through the register, pipes, etc., presumably the waste, water, or gas pipes, none of which, however, could be seen on casual inspection. These persons were also said to whisper to her through the tubes. She declared that this food language was not peculiar to herself, but was known to and in constant'use by aU the attendants and patients; that her conversation and letters were com- municated or perhaps telegraphed about the house, as she inferred, by • single words, said by different persons, in various places, in the midst of theii- conversation, and by putting these detached words together she found out by something in her heart or chest — not in her head — that they had become acquainted with the letters she had T^-i-itten and the conversations she had had with others and presumaljly with herself. '■'• It was very evident, said the judge, that 3Iiss Dickie was of unsound and imperfect mind and understanding, yet for an houi- and a half she had given no positive signs of absolute mental derangement. She knew who and where she was, described the institution as a house of afiliction. but she made no allusion or complaint of her fellow-sufferers, or of any noises or annoyances except the imaginary whisperings through the tiil:»es. She was conscious of her own weakness and ignorance of many things ; seemed satisfied to have as her guardian a bank president, whom she named, as she was not accustomed to deal with large sums of money. In short, she presented the usual mixture of reason" and unreason so common in many simple lunatics. Sometimes she exhibited a good deal IXSANITY IN ITS MEDICO-LEGAL BEARINGS. 141 of tact and cunning, at other times of extreme cliildislniess and sim- plicity, mixed up with delusions, hallucinations, unf(junded suspicions, extreme prejudice and hatred, great Christian piety, charity, and benevo- lence. " The only question that coidd arise was whether it was absolutely necessary to retain her in the asylum. There seemed no objection to a trial elsewhere, provided all her property should not pass into the hands of strangers and irresponsible persons ; that a proper residence should be selected where her peculiarities should not become the sport of the foolish and indiscreet ; and that a competent maid, nurse, assistant, or matron could be found, possessed of unmeasured patience, tact, and reso- lution." This action illustrates the conflict that frequently arises in cases where medical men bring to their aid their experience in other cases. This patient was evidently a chronic delusional lunatic, and although her history had been a harmless one she evidently owed her improvement to the care of an asylum, and was not there subjected to the disturbing irritation which she subsequently would have been affected l)y outside. Every one is familiar with the cases of so-called harmless lunatics who have been liberated. In many such instances the removal of all restric- tion has resulted in a train of disorderly conduct, extravagance, family quarrels based upon delusive ideas of persecution, foolish marriages, and insane wills. In such cases it undoubtedly happens that sometimes the patients may fall into the hands of designing guardians, so that the legal action may prove rather a curse than a blessing. The legal duty of commissions is to prove the general existence of insanity, and for that reason the courts are apt to ignore isolated or limited evidences unless they be especially dramatic ; on the other hand, the desire to protect the patient is such that minor indications of es- tablished degenerative insanity are disregarded. For this reason the law, as will be shown hereafter, looks with suspicion upon e^ddences of moral weakness, no matter how suggestive they may be of mental dis- organization.* It was held in the case of Patterson (4 How. Pr. S-l) that the retro- speefire finding of a jury regarding the acts of a lunatic or habitual drunkard is only presumptive and not conclusive evidence of incapacity.! Ordronaux,J in commenting upon these cases and that of Wadsworfh vs. Sharpsteen (14 Barb. 169 ; affirmed in 8 N. Y. 388), where the reverse was held, considers that a possible lucid interval was overlooked in the latter, and concludes : " Legally considered, every form of lunacy inqihes the possibility of an intercurrent lucid interval; and until that possil)ility is judiciall}^ declared never to have borne fruit, the only proper infer- ence is that it may have done so ; and consequently that an inquisition which overlooks the question of lucid intervals is only presunqitive and not conclusive evidence of past continuous incapacity." {Searles vs. Har- vey, 6 Hun, C58.) The finding of a commission that a person is insane is only j^rhua facie evidence of business incapacity so far as a third per- son is concerned, nor are they competent to dissolve a partnership. This * Titcomh vs. Taniyle, 84 111. 371 : Jacox vs. Jacox, 40 Mich. 473 ; Fcntrus vs. Fentnis, 7Heisk (Tenn.), 428; etc. t Van Dciifioi vs. Sweet, 51 N. Y. 378. t Mcdiccd JurisprHdence of Insanitij, ji. 247. 142 ^ SYSTEM OF LEGAL MEDLCLNE. must be determined by a jndge, who takes into account all tlie features of the case, the degree of the unsoimdness, and whether it is recover- able. tra^t:rse. If it is desu-ed to traverse the finding of a commission, the lunatic^ his friends, or any one legally empowered to act may make apphcation. This includes those who may have had contracts with hiin, or who have been or are likely to suffer by his acts* The court will protect the in- terests of the lunatic during the pending of the proceedings.t Apphca- tion for a traverse should be accompanied by affidavits and the service of papers upon the op^Dosiiig counsel. Suits may be brought in behalf of the committee of estate ; but should the complainant himself be a lunatic, the defendant may demur when it is the custom to appoint a guardian to aj)pear in his behalf. According to section 375 of the new Code of Civil Procedure, the limit of time in which a lunatic may bring action to recover real propertj^, or enter a defense or coimter-claim founded on the title of real property or the income therefrom, "is not a part of the time limited in that title (twenty years — sections 365, 366), except that the time so limited cannot be ex- tended more than ten years after the disabihty ceases." (Ordornaux.) In the case of BaJier vs. Balier,^ where an action for divorce was brought against the lunatic's wife, it was held that the committee of the estate and not the committee of the person should bring the suit. In the committee of the person or estate is vested the right to defend or bring suit whenever it may be necessary to question or stand by the contracts of his charge before the deprivation of civil rights.§ A lunatic cannot be restrained unless he is dangerous to himself or to the community becaiise of his violent acts, or that he may wander about and get into harm's way. To specify these would be to go over much of the ground we have ti-aversed. It is clearly proper to send such a person to an asylum for treatment when the facilities for it elsewhere are inadequate ; and in the hght of skilled experience, isolation is deemed an early and important requu-ement in most forms of insanity. Various authorities insist upon the fact that because a person is a fit subject for an inquisition, it does not foUow that he is to be incarcerated. The apprehension or removal of a patient from one State to another for the purjjose of avoiding legal or other consequences may be thwarted by the application for a commission ; in fact, persons who have so spirited lunatics away have been obhged to return them. (Wykeham, 1 Tm-n. & Russ. 587.) * Christie, 5 Paige, 242 ; Giles, 11 Paige, 243 ; Hale, 7 Ves. 261 ; Roberts, 3 Atk. 308. t WendeU, 1 Johns. Ch. 600 ; Russell, 1 Barb. Ch. 42. i L. R. 5 P. D. 145. ^ Carter vs. Bechicitli, 128 N. Y. 312. In 1855 defendant's intestate was adjudged a lunatic, and a commission issued. In 1871 the plaintiff, an attorney, instituted pro- ceedings in his behalf, wliich failed, to sui:)ersede the commission and have his prop- erty restored to him. In 1875 the lunatic died, and plaintiff brought this action for his servdees against the administrators of said lunatic. Judgment for plaintiff was affirmed, the court holding that while a hinatic in the cTistody of a committee is in- capable of making a contract, and no claim thereunder could l3e enforced against his estate, at his death tlie claim must be adjusted and settled in like manner as other claims against the estate. lySJNITY IN ITS 2Jh'l)IC0-LEGAL BEAllIMJS. 143 TORTS. The i'e8p<)iisi))ility of a hnuitic for iiialicious acts (lepciids upon tlie extent of his dh'ect partici2)ati()n and capacity, and his HaV)ility is tiius limited. "A hmatic is hable for his torts so far as to subject his estate to a suit for damages reverted to others by his negligent management. On principle, however, he cannot l)e lield liable for malicious acts in cases where he is not caput doU." (Wharton and Stille.) Tiie French courts in the case of MuniOiis vs. Bnuird {Jouriud da rooks in com't is not allowed where such authoiities are introduced as e^ddence ; but they uuiy be read to a witness for the j^iu-- l)0se of ascertaining how far they agree with the opinion expressed by him. He may be examined as to the standing of other experts or authorities, but should be careful in expressing his opinion of a personal nature. Under the hiAvs of the State of New York and some other States, a physician is not permitted to disclose information derived in the man- agement of a patient, unless the latter authorizes and requests him sa to do. The compensdtioii of ^'' expert^'' wifuessc^ and allowance are usual when they give expressions of opinion, or when time and labor have been expended in the preparation of the case. There is no impropriety iu * Whartou on Evidence, section 434. 150 ^ SYSTEM OF LEGAL MEDLCLXE. declaring tlie fact that coinpensatiou is expected ; and tliongli bound to give medical testimony wMch deals witli matters of fact for no other compensation except the fees of ordinary witnesses, it does not appear that any opinions implying the exercise of special knowledge which has "been gained at the cost of time and money should be given gratiiitonsly. (See vol. i. p. 614.) It has been held that the findings of a post-mortem examination do not constitnte expert testimony, and thongli the witness is entitled to pay for making such an examination, he shoidd be compelled to testify.* The case of Bills vs. The State of Indiana, 59 Ind, 15, is one which altered the statutes of that State so that at present the gi^■ing of exjDert testimony is compulsory. This is the case of Dr. Thomas J. Dills, who was committed for contempt in the Hamilton Case, mth Dr. Buchanan. He ref nsed to answer the questions referred to in the Buchanan Case, saying : " I did not offer my services here any more than I do my pro- fessional services elsewhere. I was sent for and have come. My time and my skill are my capital, and I cannot sm-render them gTatuitously to any but the poor, since it is by my professional opinion that I earn my living. There is a distinction between a man who sees a fact, and is called to prove it in a coui-t of justice, and a man who is selected to give his opinion on a matter with which he is peculiarly conversant, from the natui-e of his emplojnnent in life. The former is bound, as a matter of public duty, to speak to a fact which happens to have fallen within his knowledge ; without such testimony the course of justice would be stopped. The latter is under no such obhgation. For the above-named reasons I respectfully decline to give the opinion of an expert in the case now pending, except upon the pajanent of my fee in advance." In this case Biddle, C. J., wrote an elaborate oj)inion for affirmance, which was, how- ever, dissented from by a majority of the judges, and the judgment was therefore reversed. EXAJ\nNATIOX OF THE PATIENT. The duty of the physician is one implpng a most serious responsi- bility, for upon his say largely depend the freedom and peace of mind, the iDusiuess interests, of a feUow-man, and the happiness, perhaps, of a fam- ily. His neglected obligation to society may also be questioned, should he make a mistake and permit a dangerous lunatic to go at large. Finally, his own professional position may be compromised by a blunder, and he may lay himself open to censure of all kinds, as well as a possible lawsuit. It therefore becomes him to use the utmost care and careful exercise of * Summers vs. The State, 5 Tex. App. 365. On the trial of Summers for murder. Dr. Arthur E. Spohn was called as a witness for the State, and testified to linding the deceased injured and having attended him until he died. He also stated the nature of his injuries. After death he made a post-mortem examination, but refused to state the cause of death, claiming that his knowledge was obtained by professional skill ; and the eom*t sustained him. Summers was convicted, and on appeal the refusal of Dr. Spohn to testify was noticed, the court saying : " The coiu-t may compel a phy- siician to testify as to the result of a post-mortem examination. . . . Dr. Spohn has doubtless been misled, in taking the position he did, by the misconceptions of cer- tain writers on medical jurisprudence. ... A medical expert could not be compelled to make a post-mortem examination unless paid for it ; but an examination having already been made by him, he could be compelled to disclose the result of that exam- ination." IXSAXITY IX ITS MKDICO-LECAL liEAIlIXOS. 151 judgnieiit ill furniiii<;' uu opinion. He should put into oi)eration a system of iuvestigiition ))y wliieh he can learn the patient's antecedent history, habits, feeliiiiifs, associations, and (conduct generally, and should deter- mine the time and manner of departure from ordinary mental health, and the evidence of weakness. As many sources of information as possi- ble should l)e made use of, and the statements of interested i)ersons be given their proper W(?ight. Business papers and letters and other pro- ductions of the alleged Irmaticr written, when not under oljservation or at a time when he did not siis])ect he was watched, should l)e inspected, and will often give a clew to tlie nature of the disease. So far as the a<^tual ■examination itself is concerned, I would advise as constantly as possible the maintenance of an attitude of perfect frankness. It is only the due of the alleged lunatic, and, unless his conduct is palpably disorderly and his attention unfixed, he should l)e engaged in conversation as a sound person. Siuili a conversation, if sufficiently extended, will nearly always result in the discf)very of his delusion or other evidence of aberration. The ftrst part of this article contains information that will serve as a hint to the examiner, l)ut every case has its own peculiarities, and the use of tact and patience will, with a knowledge of the featiu^es of mental dis- ease, help the physician more than anything else. Tardieu suggests the following ])oints : "(a) Mfittal ^taie. — Three orders of facts should be investigated: 1. The intellectual troubles. 2. The perversion of the affective faculties and the instincts. 3. Alteration of the sensorial fimctions. "The intellectual disorders consist in a general derangement, marked by delirious conceptions, with or without complete abolition of judgment, memory, and conscience ; afterward commonly in a partial derangement of understanding. From a medico-legal point of ^dew the most direct and immediate result of the disorder of the intellectual faculties is a perversion of will and a resulting impairment in action, either in an absence of control or purpose, or in action which bears the impress of incoherent or erroneous ideas. " Disorders of the affective faculties are constant in insanity. There is more or less alteration of affections and instincts. The more natural sentiments are abolished or perverted, and the instinct is sometimes abolished as w^ell. " The sensorial troubles are singular and characteristic in insanity, and hallucinations and illusions are the most important. . . . "(6) Soniatir State. — The position, attitude, walk, gestures, the dress, malformationof head, physiognomy, expressi(m. . . . The circulation and temperature are diminished in the inaction of melancludia and increased in the agitation of mania. The general sensibility is exalted or perverted in monomania, or diminished to the point of analgesia in lypemania. The spasms, the startings, the muscular twitchings, the partial paralyses of sensation and motion, indicate a gi-ave alteration of the nervous cen- ters. The embarrassment of speech, the unequal dilatation of the pupils, the permanent deviation of the uvula, the ataxia of movement, suggest genei-al paresis. Finally we are to recognize all the symptoms which are connected more or less directly with nu-ntal alienation : vertigo, muscas volitantes, cutaneous and neuropathic manifestatiims, the mobility of the tongne, and scars which may ])e indicative of epilepsy, or traces of cica* trices which may be the result of attempted suicide." 152 -4 SYSTEM OF LEGAL MEDICINE. "habitual drunkards." It is an important matter to determine what constitutes " liabitiial drunkenness," and courts of law take widely differing views. In the case of Blcincy vs. Blancij, 12G Mass. Reports, 205, a decision was rendered in an action for divorce on the ground of habitual drunkenness. It wa& proved that defendant for twelve or fifteen years past became grossly intoxicated at least three times a year, and remained in that condition from seven to ten days each time ; that when these sj)eUs came he was sent to an inebriate asylum, where he remained until thej passed ; that between the spells he would drink nothing, but that any excitement would make him drink. Held, on appeal to the Supreme Court, that this was sufficient proof of habitual drunkenness. In the case of Wheeler vs. Wheeler, 53 la. 511, a divorce was granted the plaintiff, who was the victim of the husband's violence during his drunken excesses, although at other times he was sober and was able to conduct his business. The plaintiff and defendant were married in 1859.. Previous to that time defendant was addicted to liquor, and was fre- quently drunk. After his ma,rriage he became an habitual drunkard, and his wife sued for a divorce on that ground, and also because of inhuman treatment. The divorce was granted. Although he was always sober during business hours, he was habitually drunk at other times, and when in that condition abused his wife, calling her vile names and openly charging her with unchastity. On appeal the Supreme Coin-t affirmed the decree of divorce.* The English Habitual Drunkards' Act of 1879 defines an " habitual drunkard" as a "person who, not being amenable to any jurisdiction in lunacy, is, notwithstanding, by reason of habitual intemperate drinking- of intoxicating liquor, at times dangerous to himself or herself or to others, or is incapable of managing himself or herself, and his or her affairs." (Kerr.) In England such an habitual drunkard may be com- mitted to a retreat, either upon his own application or upon the affidavits of two persons, for a period not exceeding twelve months. He is in all respects treated like an insane person, so far as his loss of liberty is con- cerned. In the United States the only way in which it is now possible to have an habitual drunkard secluded is through the intervention of the police — the occasion of some disorderly act being chosen for a com- plaint. If his habitual drunkenness is connected with symptoms of in- sanity, he may of com-se be committed to an asylum or institution as any other lunatic, but superintendents of asylums are not disposed to detain * Mary Williams (wife) vs. J. W. Goss (husband), 43 La. Ann. 868. This was an action for separation on the groimd of habitual intemperance. The defendant owned a small store, of .which liis wife had been the head for several years. It was shown that he " was addicted to excessive drink " ; drunk often two or three times a week ; had frequently been undressed and helped to bed ; was frequently away from home all night, and often carried home drunk by strangers. He had often taken seven or- eight drinks a day in one store, and sometimes bought by the bottle — fifteen cents' worth. He had locked himself in a bedroom on one occasion, and with a loaded gun lay in wait for imaginary assassins. He had been on sprees of three or four days at a time, and was known as " a drinking man." There was no evidence that he had be- come v'hollji incapacitated for business. The decree was granted, and the Supreme- Court affirmed the judgment. IXSAXITY IX ITS MEDICO-LEGAL BEAIUXGS. 153 such subjects unless the departure from mental health be a prolonged and clear one. The use of the word '' di-unkenness " does not inchide the intoxication produced by other agents, as was held in the case of Youn(/s vs. Yoioujs, 130 111. 230.* Tlie commitment of an inebriate may often lead to very disagreeable results — the medical men or the friends being sometimes sued by the person committed. The case of Jason L. Blodgett, reported by Dr. Fisher {Boston Medical and Surgical Journal, June G, 1881), .is so interest- ing that I may be pardoned for referring to it rather extensively, using the reporters' language. " A suit was brought two years ago in the Massachusetts Supreme Court by Jason L. Blodgett against his divorced wife. Major Jones, now on the Board of Police Commissioners of Boston, and Drs. Fisher and Youngmau for a conspiracy to imprison him in the Taunton Lunatic Hospital on the false charge of insanity ; also for assault and battery in causing his arrest ; and for taking his property, ruining his business, and causing great damage to his reputation and feelings ; for all of which damages to the extent of $15,000 were claimed. His legal adviser at first was "WilUani H. Towne, who afterward called to his assistance Ed- ward Avery. The defendants were represented by Edward P. Brown. At the first trial the plaintiff's petition was dismissed for informahty and illegal contents. Major Jones was excused, as having had nothing to do with the particular commitment complained of, the plaintiff having been sent to Taunton twice ; and Mrs. Blodgett, having been his wife at the time of the alleged offense, could not be proceeded against. This left the two physicians standing alone ; and after six months the case was called again, unexpectedly, at the close of the summer vacation, when police officers, who were ini23ortant witnesses, were absent. The "v^afe, whose testmiony was almost absolutely essential to the defense, had liid- den herself from her divorced husband in the far West, and could not be compelled to attend or obtained as a witness without great expense. The jilaintiff told a story based on his confused recollection of events, and deliberately false in some parts, which was contradicted by the defend- ants, who offered to put in as the basis of their certificate infoi-mation received upon ' due inquiry,' as well as the result of personal examina- tion. This hearsay testimony, though required by law as part of the foundation of the certificate, was not admitted in its support at this time, and the wife being absent essential facts were kept out of e^•idence. The rulings of Judge Endicott were in every other way favorable to the de- fendants. The jury disagreed, as the foreman afterward stated to Major Jones, by permission of the court — nine for the defendants and three for the plaintiff, on the question of ' lack of due inquiry ' only. Xo suspicion of a conspiracy was entertained by any juryman. " The case was again called last spring, the wife still being absent. The plaintiff, with one or two unimpoi'tant exceptions, was his own ^vit- ness, and made the same or similar false statements as before, showing * Plaintiff filed a bill for divovec, cliai'giu<]: halntual dnuikeuness. There was proof of the excessive use of morphine liy hypodermic injection, on AThich the charire of drunkenness was based. The bill was dismissed, and the Supreme Court affirmed the judgment. After reviewing the various definitions of the word ■' drunkenness " tlie court said : " It cannot be held to include intoxication produced by the hypodermic administration of morphine." 154 -4 SYSTEM OF LEGAL MEBICLNE. •clearly on the stand to medical observation the nnreliable and irresponsi- ble nature of his mental operations. The case was classified as dipso- mania on all the certificates offered, of which there were three. The following is a brief sketch of the plaintiff's history : " At the time of the trial he was a man about forty years of age, of evidently neurotic constitution, impulsive, excitable, with a loose way of expressing himself, said to have been characteristic of hiin from youth. One witness testified that he had always been given to telling untruthful and inconsistent stories. He was reported to have had an aunt who was insane. His father was a clergyman, and both his parents died in his early youth of consumption, leaving him in charge of his relatives. He was a bad and irregidar scholar, though quick-witted enough for mis- chief. At the age of puberty he showed a proneness to premature vicious conduct of various kinds. He is said to have begun to di-ink by sprees at the age of fifteen years. He had some good traits and impulses, but was earty the slave of his appetites, and was cursed with a craving for drink. His sister says he was a good brother when sober, but a ' perfect devil' when di'unk. '' He was in frequent trouble on account of his scrapes, both in the country and in Boston, until the war broke out, when he enlisted. Hav- ing previously lost the sight of one eye, it was still further injured by a thorn, and was enucleated. He was then put on an army freight-train as conductor or brakeman, and continued to serve until the close of the war. After the war he was employed on railroads at the West, leading a life of active dissipation, according to his own admission to a witness. In 1875 he came to Boston, claiming to have reformed, and that he was the possessor of a large sum of money. In this belief a widow of the former proprietor of certain Turkish baths in Boston — herself being the owner at that time — married him. His fortune proved mythical, and his wife was obliged to pay for his wedding-suit and for the wedding-jom-- ney; she gave him a gold watch, and supported him ever afterward, except for the small value of his services in the baths. He obtained control of all her property, and in a very short time developed a tendency to drink by sprees, in which he was ugly, viok^ut, and dangerous, threat- ening his wife in particular. He was seldom seen drunk in the ordinary way, but was exalted and maniacal, acting more or less automatically, and failing to remember his conduct and conversation afterward. It is but charitable to suppose that this accounted for his wholesale denial of numerous facts testified to by a score of witnesses on the stand. In a year or two he had spent all his wife's property and destroyed her busi- ness by his drunken conduct. " My attention was first called to him October 12, 1875, by Dr. A. N. Blodgett, his wife's physician, but not related to either party. Dr. Blod- gett, being in attendance on the wife, found the husband in a state of dehrium from drink, in which hallucinations of snakes in his bed were prominent. He thought he saw the devil in the looking-glass ; threat- ened to kill his wife ; threw furniture violently about the room ; and did not recognize Dr. Blodgett, but violently assaulted him several times. Policemen were called, and he was taken to the Tombs. The next morn- ing application was made by Dr. Blodgett to the Board of Directors for Public Institutions for his commitment to Taunton as insane. Having learned his previous history, I agreed that he might be a dipsomaniac, IXSAXITY IX ITS MEDICO-LFJiAL liEAIUXGS. I55 but, tlie present attack resembling in some of its features delirium tre- mens, advised that lie shoidd be sent to Deer Island. He did not have a perfect attack of that disease, and was discharged in two or three days, apparently rational. '' He was again arrested January 31, 1876, for violent conduct while drunk, and released on promise of good behavior, but was rearrested the same day, fined three dollars and costs for being di-uuk, ten dollars and costs for assault on a female employed at the baths, and was bound over for six months to keep the peace. He was sent to jail, and Major Jones, as bail commissioner, signed the bond on which he was released. June 24, 187(), he was arrested again, but let off on promise of good beha\'ior. xVgaiii, on November 8, 1876, he was arrested as insane. Complaint having previously been made to the board of directors, I was sent with Dr. Youngman to interview Blodgett. I learned that he had been very vio- lent at the baths, smasliiug up fui'niture and fi-ightening leathers and employees. I found him at home, an officer bringing him up from the cellar, where he had retreated, having an ax in his hand. His wife had fled from the house, and the other inmates were locked in their rooms. He was in a very ugly, sullen mood, ha\'ing been di-inking hea\'ily. He denied, as was his custom, ever drinking to excess or using violence to any one. He had recently had a spasm of religious interest ; went inta a prayer-meeting at the Young Men's Christian Association and offered any brother twenty-five dollars to convert him. A member went home and prayed with liim, but was tiu-ned out by Blodgett because he ' didn't pray worth a damned cent ' ! No sign of delirium tremens was present at this time, and it was determined to send him to Taunton as a dipso- maniac, with a view to a sufficiently long detention for his improvement or cure. He made no objection and asked for no hearing, thus acquies- cing in his commitment. " Having remained at Taunton a few weeks, he was discharged on. application of his counsel, Mr. Towne, and was sober and well behaved for a considei-able period after it. He admitted, in an interview with Major Jones, his irresistible disposition to drink, and that he presumed the allegations of violence were true, but that he did not remember what occurred at certain periods of his drinking-speUs. He had also consulted a relative in reference to some cure for his entire loss of self-control in reference to drink. He joined the chm'ch of which his wife was a mem- ber, and behaved weU till August, 1877. From August to December he had three sprees, in which his conduct was erratic and violent. For in- stance, he would rush down Washington Street in the evening With a roll of bills in his hand, flourishing them about, and followed by a crowd of men and boys. He woidd buy a pie, order a hack, and send the pie home alone in the hack. On several occasions he used vulgar, profane, and tlu'eatening language to ladies at his wife's boarding-house. December 10, 1877, complaint having been made to the board of directors, he was examined at his l:)oarding-house by Dr. Youngman and myself. We found him in bed, nervous and confused, as if from a prolonged debauch. I talked with him half an hour, explained to him my theory of his case, told him I thought nothing but prolonged detention would do him any good — that as he had improved after a few weeks in Taunton, a year would do him still more good. He denied drinking more than wns good for Imn, but said he would stop at once if we would not certify in his 156 ^ SYSTEM OF LEGAL MEDICINE. <3ase. I told liim if lie was arrested again for violent conduct I should certify. This interview, lie testified, was only a few minutes long, and lie could remember but one thing that was said. Two days after, he was arrested at the baths for furious conduct toward his wife and other ladies, and for trying to kick over a hot stove. He was sent to Taunton December 12, 1877, and asked for no hearing at this time. '' Remaining in Taunton about three months and a half, he was dis- charged March 26tli, and rearrested for throwing a bottle at some one at the baths March oOtli, four days after. The next morning he showed very little effect from liquor when seen at the Tombs, the period of indulgence having been brief. He demanded a hearing at once, and a certificate j:)ro forma having been signed to bring his case before Judge McKim, he was released on promising good behavior. In April a libel for divorce was filed by his wife, alleging brutal and violent conduct, with gross and frequent intoxication. Blodgett appeared in the anteroom of the Su- preme Court in his usual peculiar condition, insulted several ladies there with obscene talk, undertook to conduct his own defense, and harangued the court in such strange and familiar language that the judge told him he must be either drunk or crazy, and granted the divorce. His wife then left him for the West, in a penniless condition, and he soon found a lawyer willing to take his suit against the alleged conspirators. This idea of a conspiracy was, I think, in part a vague delusion growing out of imaginary wrongs, and in part a foolish attempt to rehabilitate his fortunes and revenge himself at the same time by a suit against his assumed enemies. A few weeks before the final trial he was arrested for drunkenness in Waltliam, and boasted, in his loose way, of the immense business he was doing, and the money he was going to make out of the doctors. "At the last trial before Judge Lord the preceding facts and many others of similar import were proved. Twenty policemen testified to Blodgett's habits of drunkenness, eccentricity, and to his violent actions. They all agreed that he was different from ordinary drunkards in his talk and conduct, and was regarded as crazy and dangerous when in liquor. This opinion was sustained by many sober witnesses who knew him well, and by his own confessions to Major Jones, as well as his ap- pearance on the stand. He there denied in a wholesale way all excessive drinking and all acts of violence, only to be contradicted by many relia- ble witnesses. He might, perhaps, truly have said that he remembered no acts of violence, as I have no doubt his conduct was automatic. Judge Lord allowed the facts obtained by ' due inquiry ' to be testified to in full, the other side failing to object. "A number of experts were called by the defense. Drs. "Walker, Brown, Gage, Russell, Denny, Jelly, Folsom, Channing, Day, Blodgett, Fisher, and Youngman gave their definitions of dipsomania and testified to the propriety of treating it in hospitals for the insane, in the absence of other special institutions. These gentlemen substantially agreed in affirming the existence of such a disease, and in the necessity of so treat- ing it. " The plaintiff called on his behalf Drs. Henry G. Clark, J. P. Tread- well, and Horace Chase. Dr. Clark thought a dipsomaniac must be a person who on drinking a single glass must inevitahly go on to complete intoxication. He thought Bloda-ett did not fall within this definition. INSANITY IN ITS MEDICO-LEGAL BEAMINGS. 107 He was oljlig-cd to admit, however, tliat he liad recently said that Bh)dgett Avas 'crazy drunk' and ])roi)erly sent to Taunton, but was k(^pt too lon^; iind that he had certilicd witliin three months in the case of a dan<^erous dipsomaniac committed to Danvers. Dr. Treadwell gave his views at length, and thought the part of the testimony he had heard did not warrant calling Blodgett a dipsomaniac. Dr. Chase's testimony I did not hear. "Judge Lord's charge to the jury was satisfactory in every way to the defense, and was an admiraljle statement of the rights and liabilities of physicians certifying in cases of insanity. It deserves reproduction as a whole, l)ut I will give only a very brief abstract of it. Judge Endi- <;ott had said in substance at the previous trial that it was evident from the testinu>ny that there was such a disease as dipsomania ; that the line between it and ordinary vicious drinking was a narrow one, which only qualified medical men could safely draw ; and that a lunatic hospital was a proper place for its treatment. Judge Lord, however, told the jury to reject the technicalities of the doctors, and charged that if mental un- soundness of any kind existed it was an end of the case ; that if physi- cians honestly believed the party to be insane, although they may have been misled or mistaken, they were not responsible. They were obliged by law to make ' due inquiry ' of the parties most likely to possess the facts relating to insanity, and nearest b}'- ties of relationship or affection to the patient; but they could not take sworn CA-idence in the case, and must act according to their best judgment upon the facts obtainable. Their certificate was not required by law to be under oath, and was merely the necessary means of bringing the case into the jurisdiction of the proper court, after which they were not responsible for the action of the court, unless it could he shown that they willfully gave false testi- mony, or grossly and criminally neglected to in([uire into the facts of th.e €ase. In the words of the court : ' If capable physicians should act reck- lessly, disregarding the rights of the part}-, and send him off to a hospital without any evidence at aU, then they would be responsible. But if on the other hand they made the inquiry which the circumstances of the particular case called for, then, although subsequent events raiw show that that inquiry might have been pursued further if they acted in good faith, that is theii" protection. The jury rendered a verdict for the de- fendants." The same questions here arise regarding the execution of legal papers as do where there is no toxic causation of the unsoundness, and the issues are varied and alwaj-s interesting. The case of 0' Conner vs. Rempt, 29 N. J. Eq. 156, is one of a familiar kind where undue influence was evidently exerted. This was a biU t(^ set aside a deed alleged to have been executed while the plaintiff was in- toxicated and in a state of mental aberration. The ])laintiff lodged at the house of the defendants on March 2, 1877. He had never met Mrs. Rempt, the grantee, before. He returned on the 4th of ]\[arch and from that time until the 7th was secluded by them from his friends. He was drunk when he returned on the 4th, had been on a drunken debauch for a month previously, and was delirious when he left his home. The de- fendants admitted that O'Conner was not sober when he came to them, and i\\ej allowed him to ^{ny. The next morning he was sick, and was told to go to a hospital, but he asked to be allowed to remain, saying, 158 ^ SYSTEM OF LEGAL 2LEDLCTXE. ''Toa let me stay, aud I Avill give jou all my i^roperty, and you can take care of me as long as I live. I ^vlll make it all right." On March 7th the deed was executed, after three pre\'ious attempts to obtain his .signatiu-e to it had failed, o^ving to the fact that he was in a stupor. The deed was recorded on March 8th, and a few days afterward he wa& removed fi'oni the defendants' house by the police, in a state of mental and physical prostration. On March 19th this bill was filed. The Court of Chancery declared the deed void, on the ground that "when the com- plainant went to tlie house of the defendants his mind was disordered ; that the day before the deed was executed he was all day in a state of ch'unken insensibility : and that when he was rescued from the custody of the defendants he was suffering from dehrium ti-emens." The case of Bliss vs. Conn, d: Pas. Eivfrs E. R. Co., 24 Vt. 424, is one in which the question of time-limit arose, and where the action of the Supreme Court was exti'cmely merciful and j)i'otecting. The defendants took lands of the plaintiff for theu' use, and an award was made. Under the Vermont statute then in force (1852) an appeal from an award must be' made within ninetv" days, except where disabilities exist, when the appeal must be made -within ninety days fi-om the removal of the disabilities, which are in the cases of ''married women, infants, idiots, or insane." The plaintiff for a long time was intemj^erate to such an extent as to unfit him for business, was out of Ms mind, required close watching, thi-eatened to injui'e others, burn his buildings, etc. ; and dui'ing the time the land was taken and the award was made, his family tried to talk with him about the matter, but were unable to make him understand it until the ninetv^ days had expii*ed. Afterward with his consent the appeal was made, and was dismissed by the County Coiu't on the ground that it had not been made within ninety days. The plaintiff then apiDlied to the Supreme Court for a ^^n:\t of certi- orari, which was granted, aud the judgment of the County Coui't reversed, the coiu't holding that the plaintiff was not capable of managing his affairs, and should be gi"anted the benefits of the pro%ision of the statute relating to disabilities of "insane," even though his disability was caused by his own excesses and misconduct. The subsequent ratification of a contract alleged to have been made when the person is intoxicated has been held to make parts of the trans- action binding.* THE CAPAaTY OF DEAF-]MUTES. The deaf-mute was at one time considered to be as irresponsible as the idiot, so far as testimony was concerned, in coiu'ts of law. How- ever, a much more intelligent view of the question of competency * Smith vs. WilJinmson, 8 Utah, 219. This was an action concerning a promissory note. It appears that the note was given, together with a Holstein hull, in exchange for a Durham bull. A few days afterward defendant retiu-ned the bull, and took in its place a Durham heifer, in pursuance of an agreement made at the time of the transaction. Defendant pleaded that he was intoxicated at the time he signed the note. Judgment was rendered for defendant, but the Supreme Coiu-t reversed the judgment on the ground that even though defendant was intoxicated at the time the note was signed, his subsequent action in exchanging the bull for the heifer and still retaining the heifer was a ratification of the transaction, and of his signature to the note. INSAXITY IX ITS MEDICO-LEGAL liEJIlIXGS. 159 is now taken, and it is by no means tlie rule because certain chan- nels of expression which put the individual in communication with the world are cut off, that he is entirely deprived of intellig-ence. The law is disposed to approve of the actions of persons of this kind, provided they are in no other way mentally incapacitated. The mere deprivation of the senses of hearing, sight, and speech does not hiiply weak-mindedness, althougli under the English law a deaf-mute is incom- petent to give evidence if he is also blind. Disputed wills (Jarm., Wills, uth Am. ed., chap, iii.) of deaf-mutes have been allowed to stand. Those who offer such a Avill for probate must prove the intelligence and abil- ity that constitute testamentary capacity. Judge Redfield has decided that educated deaf-mutes who make holographic wills or convey by gest- ures their intentions and wishes should l3e allowed to do so, and that such wills should stand. The affliction of coincident blindness need not necessarily change the situation. It is, however, necessaiy to differentiate the mutis'm of simple accidental deprivation or uncomphcated origin from that which is a feature of imbecility. This question arises not only in will-making, but where contracts of any kind are entered into. Dr. Peet, who has had very wide experience with the deaf and dumb, gives the following general principles in regard to their rights and responsibilities : "A deaf-mute who has no knowledge whatever of wi'itten languages may yet, if his dialect of gestures is sufficiently copious and precise, possess the intelligence necessary to manage his own affairs, to make all civil contracts, to execute a deed or a will, or to give evidence in a court of justice. But as the degi-ee of intelligence and of moral development in uneducated mutes is very various, some who have been neglected in infancy being but a step above idiots, they should be carefully examined to ascertain whether they really possess the necessary degree of knowl- edge and intelligent will. With respect to the formalities used, it may be laid down as a general rule that the deaf-mute who can read and write but imperfectly or not at all should be regarded as in the position of a German or Frenchman whose ignorance of our language necessi- tates the employment of a sworn interpreter between him and the court. But when the \leaf-mute can read and write well the best mode is that prescribed in the French Code. In the case of such, reading supplies hearing and writing supplies speech. Hence it folloAvs that a paper pre- sented to a well-instructed deaf person, calling his attention by pointing with the finger to the writing, should be considered as read to him, it being understood, of course, that there should be sufficient light and sufficient legibility of writing. We think, however, it ought to be specially enacted that a legal service, in the case of such persons, should consist in giving them a copy of the writ or notice to be served, inform- ing them in writing of its nature and contents: and in the case of deaf- mutes who cannot read, or l)ut hnperfectly, the reading may be accom- pHshed by the aid of a competent interpreter. Any legal oath or obligation may lie taken or assumed by a well-instructed deaf person by writing out with his own hand the formula before witnesses, with such fornis of solemnity as the occasion nuiy demand, or by a conversation in writing with the officiating magistrate." There can be no question as to the right of the deaf-mute to the ser- vices of a competent interpreter. 160 A SYSTEM OF LEGAL MEDLCLNE. The matter of accident cases resulting in traumatic insanity has not been here considered, but the reader is referred to subsequent articles 'hj Dr. Dana and Mr. Godkin which cover the ground both as to the medical and legal jDoints. BIBLIOGEAPHY These references, of coui'se, include a small part of the literature of the subject; Taut many of the works referred to have been used in the preparation of this article, and others are suggested for the aid of the reader. 1804. iSll. 1811. 1812. (1 (2 (3 (4 1814. (5 1817. (6 1818. (7 1819. (8 1820. (9 1825. (10 1826. (11 1826. 1827. (12 (13 1827. (14 1829. (15 1830. (17 830. (18) 1832. (19 1832. 1832. (20 (21 1833. (22 1834. (23, 1835. (24; 1836. (25 1837. (26 Covibe, A., "Practical Observations on Insanity," etc. London. Beck, T. B., '' On Insanity." New York. Croicther, B., "Practical Remarks on Insanity," etc. London. Busli, B., "Medical Inquiries and Observations upon the Diseases of the Mind." Philadelphia. mil, Gr. K., "An Essay on the Prevention and Cure of Insanity," etc. London. Foclere, ' ' Traite du Delire, Apj)licxue a la Medecine, a la Morale, et a la Legislation." Paris. Boekr, " 1st die von einem Wahnsinnigen in einem Lucido intervallo be- gangene Handlung ziirechnungsfahig oder nicht?" "Arch. f. med. Erfahr.," vol. i., pp. 429-469, Berlin. Fiiiel, S., "Eecherches sur Quelques Points de 1' Alienation Mentale." Paris. Burrows, G. M., "An Inquiry into Cert. Errors Eel. to Insanity," etc. London. Reinroth, J. C. A., '■'■ System der psyehisch-geriehtlichen Medezin," etc. Leipzig. Bonfils, J. L., "Sur la Jimsprudence Medicale Eelative aux Alienes." Paris. Guislain, "Traite sur I'Alienation Mentale," etc. Amsterdam. Rojfhauer, J. C., "Medeciue Legale Eelative aux Alienes et aux Sourds- mtiets," etc. Paris. Brierre de Boismont, "La Medecine Legale des Alienes." "Clin. d. Hop.," vol. i.. No. 85.3, Paris. Marc, " Materiaux pour I'Histoire Med.-Leg. de I'Alienation Mentale." 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Testu, €., " Quelques Considerations sur les Causes et le Siege de I'Alie- nation Mentale." Paris. Prifchard, J. €., "A Treatise on Insanity and Other Disorders Affecting,' the Mind." Philadelphia. BIBLIOGRAPHY. IGl 1838. (27) Morison, A., " The Pliysiosnomj' of Mental Diseases." London. 1838. (28) J. 286; vol. iii., p. 193. 1855-56-57. (47) Tulce, D. H., "On the Various Forms of Mental Disorder," Lon- don, "Asyl. J. Ment. Sc," vol. ii., p. 445; vol. iii., pp. 81, 218, 335, 443. 1855. (48) Noble, D., "Elements of Psychological Medicine." etc. London. 1855. (49) Piorry, P. A., " De la Folic" et du Delirc," etc. Paris. 1856-57. (50) Crawford, J., " Feigned Insanitv," etc. " Glasgow M. J.," vol. iv., pp. 35-41. 1857. (51) Ideler, K. W., "Lehrbuch der gerichtliehen Psychologic." Berlin. 1858. (52) Locicenliardt, S. E., " Kritische Untcrsiichuug iiber zwei Strcitfragen aus dem Gebicte der gerichtliehen Psychologic," etc. Breslau. 1858. 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Med.,"' vol. xix., p. 110; vol. xx., p. 161 ; vol. xxi., p. 81; vol. xxii., p. 241; vol. xxiii., p. 126; vol. xxiv., p. 185; vol. xxv., p. 23:5; vol. xxvi., p. 241; vol. xxvii., p. 249; vol. xxviii., p. 2.30; vol. xxix., p. 241; vol. xxx., p. 401; vol. xxxi., pp. 368, 409, Niirnberg. 1880. (168) Westphal, C, " Psychiatric und psyehiatrische Unten-icht." Berlin. 1880. (169) Html, H. M., "Recent Jud. Decisions in Mich. Rel. to Insanity." "Am, J. Insan.," vol. xxxvii., pp. 23-35, Utica. 1880. (170) Miclic, "General Paralysis of the Insane." London. 1880-83. (171) i)'«H/«(?, "Lemons sur les Maladies Mentales." Paris. 1880. (172) Fohom, C. F., "Four Introductory Lectures on Insanity." Cambridge. 1881. (173) Von Krafft-Ehhiy, Ii., "Lehrbueh der gerichtlichen Psyehopathologie," etc. Stuttgart. 1881. (174) Dagonet. "Conscience et Alienation Mentale," etc. Paris. 1881. (175) HiKjhes, C. H., "Illusion, Hallucination, and Delusion," etc. "Alienist and Neurol.," vol. ii.. pp. 32.5-333, St. Louis. 1881. (176) BaiiDie, "Quelques Materiaux Apportes a la Medecine Legale des Alienes." "Ann. Med.-Psyeh.."' vol. vi., pp. 264, 446, Paris. 1881-82. (177) Campbell, J. A., "Complaints of Jnsane Patients." "J. Ment. Sc-," vol. xxvii., pp. 342-352, London. 1882. (178) Billod, E., "Des Maladies Mentales et Nerveuses," etc. Paris. 1882. (179) Wharton, "A Treatise on Mental Unsoundness," etc. Philadelphia, 1882, 1882. (180) Griesin(jer, W., "Mental Pathology and Therapeutics." Translated from the German. New York. 1882-83. ilSl) Ainadei, / : 25. " 2Ioral Insanity " : 26, 30, 98, 125, 147, 223. Phiisio(inomi/ : 27, 55, 73, 189, 197. Classification and Vital Statistics: 32, 37, 46, 47, 63, 76, 83, 87, 117, 153, 215. Evidotce of tlic I)isane : 126, 177. Tlic Insane Ear : 127, vol. v. Alcohol, Morphine, etc. : 202, 204, 219. Idiocy and Imhecility : 207, 214, 232, 239. Insanity of Children : 210. Hi/pnotism and Somnambulism: 206, 211, 213, 217, 218, 220, 221, 227. Paranoia : 205, 212, 214, 222, 224, 225, 228. Xcurastlieniu : 233. MENTAL RESPONSIBILITY OF THE INSANE IN CIVIL CASES. BY CALVIN E. PRATT, Justice of N. Y. Supreme Court. Insanity is the generic term which includes lunacy, derangement, mania, frenzy, madness, delirium, alienation, aberration, dementia, and monomania ; each of these terms has a well-known definition, and each form of mental disease has its well-marked symptoms and characteris- tics. No definition of insanity is entirely satisfactory to all lawj-ers or doctors, or seems to cover all cases that can arise. Cases of what is called emotional insanity, morbid and irresistible impulse, hj-pnotism, epilepsy, moral insanity, and various abnormal mental manifestations that occur, or are claimed to occur, make it difficult to construct a short and simple definition fit for practical and universal use in coui-ts of jus- tice. Perhaps as satisfactory a definition as can be given in a patholog- ical sense is that of Dr. Hammond : '' That person is insane whose mental processes are directly at variance with those of the average human mind." This is a medical definition. In laAv, however, the ques- tion is not whether insanity exists in a medical sense, but whether there exists that liind and degree of aberration of mind or incapacity which will shield a person from punishment for crime, annul liis contracts, or set aside his will. It would be interesting to trace the changing and complicated history of forensic insanity from its foundation in the Roman law to the present tune. Such an effort will involve a critical examination of all the Eng- lish and American cases where the subject has lieen judicially considered, and will not aid much in ascertaining the legal relations of insanity at this time. The radical changes that have taken place in the last century in regard to the criteria of capacity and responsibility in mental disease might well be termed a revolution. Tliese are due chiefly to the great prog- ress made by the medical profession in the knowledge of diseases of the mind, and their use as experts in courts where such issues were involved. It is only by a trial and decision by a competent court that a principle of medical jurisprudence can be said to be estal^lished, and hence the most recent decisions are to be regarded as the true enunciations of the principles by which we are to be guided in considering the legal tests to be applied in this class of cases. It is not necessary to allude to the com- mon-law definitions of insane persons, lunatics, idiots, non compos mentis delusions, illusions, and monomaniacs, as the term unsound mind may, for all practical purposes, be held to include every species of insanity or mental unsoundness in courts of ci\-il jurisdiction. 1G9 170 ^ SYSTEM OF LEGAL MEDICINE. Cases invohdng qnestions of unsoundness of mind or insanity in every form are divided into two classes, civil and criminal : the first is one of capacity to do a particular act in question, siich as making a con- tract or will ; the second is one of responsibility for an act or omission, such as an assault or homicide. Perhaps, as a general rule, it may be stated that, in regard to contracts generally and testamentary capacity, no man is regarded as of unsound mind unless he is " incapable of appre- ciating the nature, and forming a rational judgment upon the results, of the particular act which is the subject of judicial consideration." No such general rule can be stated as apjjlicable to capacity and liability of insane persons in the criminal law, as the rule is not uniform in England or the various States of America, neither do the judges and medical ex- perts fully agree as to a proper rule of responsibility. The rule in the State of New York is in substance as foUows : " Was the person whose act is in question laboring under such a disease of the mind as rendered him incapable of knowing the nature and quality of the act and that it was "v\T.^ong?" There are many distinguished experts who claim, with great force of reason — and the principle has been held by many able judges — that another element should be regarded as a valid exculpatory plea, to wit, loss of self-control from any disease of the mind. The ride would then be stated as follows : ''Was the person whose act is in ques- tion able to understand the nature of the act and pass a rational judg- ment on its consequences to himself and others, and was he a free agent so far as that act was concerned ? " and such will undoubtedly be the rule in the near futui'C. We will now examine the legal relations of insanity or unsoundness to certain specific issues relating to the f ollo-vving subjects : wills, eon- tracts, including contract of marriage, torts, and expert testimony. The medico-legal issue in cases regarding wills is whether at the time of making the will the testator possessed testamentary capacity. The rule upon this question may be tersely stated as follows : " In order to make a valid will a testator must have sufficient capacity to comprehend the nature of the act he is performing ; he must understand the extent of the X->ropert3'' of which he is disposing ; he must comprehend the rela- tion which he holds to those who have claims upon him, and be capable of making a rational selection among them." {Am. & Eng. Encydop(edia of Lmv, vol. xi., p. 151, and cases there cited.) The rule above cited is explained and illustrated by judges according to the facts and circumstances developed in each case under considera- tion. For example. Lord Cockburn, in the case of BanAs vs. Goodfellow, L. R. 5 Q. B. 549, stated in relation to the last clause of the rule: "He must be able to comprehend and appreciate the claims to which he ought to give effect, and, mth a view to this effect, that no disorder of the mind shall poison the affection, pervert his sense of right, or prevent the exer- cise of his natural faculties; that no insane delusion shall influence his mil in disposing of his property, and bring al)out a disposal of it which, if the mind had been sound, would not have been made." The burden of proof is always upon the party that propounds the will for probate to establish its validity. 1. He must prove that the statutory requirements have been complied with. 2. That, by the subscribing witnesses, the testator appeared to under- MEM'AL RESPONSIBILITY OF THE INSANE IN CIVIL CASES. 171 stand the business in which he was engaged; hut, in ease the sub- scribing Avitnesses are dead or cannot be produced, tlie proponent of the will can rest upon the presumption that every man is presumed to Vje sane imtil some evidence to the contrary' is offered. (68 N. Y, 409, 7 Pick. 94.) Where, however, a party has been proved to be insane, the presumption is that it continues, and the bui-den then shifts to the party alleging sanity {Am. lO £»(J- £iiC!/clopadi(i, vol. xi., p. 160), and he must prove that the will was executed during a lu('id interval. It will at once be perceived in this class of cases tliat a gi'eat many questions arise as to the kind and degree of insanity, and how mucli in- fluence it had upon the testator in the making of the will. The insanity may be chronic or acute, or it may be the result of disease or accident. It has been held that extreme old age, excessive use of intoxicating liquor, strong beliefs, existence of mental delusions, licentiousness, and unreasonable prejudice against relatives are not necessarily incompatible with mental capacity or intelligence to make a will. (Same volume of Am. tO UiKj. Enrydopei\son to testify in coiu't. It is a matter for the com-t to determine. The rule Ijy which the court is guided is as follows : " In order to be competent the person must he j^ossessed of such an understanding as enables him to retain in memory the events of which he has been a witness, and gives him a knowledge of right and wrong sufficient to appreciate the sanctity and binding force of an oath, {Am. d; Enrj. E}i(:ydopmdia, vol. xi., p. 145, note, and eases cited.) INSANITY AS AFFECTING CONTRACTS. As a general rule it requires a higher degree of capacity to make a contract than a will, depending somewhat upon the nature of the trans- action, i.e., the complexity of the subject-matter. The most coinmon cases relate to deeds, commercial paper, and partnership. The deed of an insane person is either void or voidable. It is void when given by an insane person for whom a committee has been aj^pointed in whom his estate is vested. In all other cases it is voidable. In order to inval- idate a deed of an insane jjerson the suit must be instituted by the grant- or after he is restored to reason, or by his committee or guardian, or by his executor, administrator, or heirs. {Am. d: Enrj. Eucijchjjaclia, vol. xi., p. 149.) These rules apply to all persons non compos mentis or labor' ing under delusions. All the authorities upon this subject, and uj)on ratification and executing contracts for the sale of land, are to be found in the same volume lief ore mentioned, at pages 150 and 151. It may be stated that the insanity of a maker or indorser of a prom- issory note may be set up as a defense to an action u2)ou the note by the payee or any persons having notice of such disability, or of such facts as would put a reasonable man upon inquuy as to the competency of the maker or indorser. But where the insane party has received full consideration, and the note inured to his benefit, and it has passed into the hands of a hona-fide purchaser without notice, insanity is not a de- fense to the note. It has been held, however, that an accommodation in- dorser of a promissory note who receives no benefit therefrom, either to himself or his estate, may defend on the ground that he was non compos mentis at the time of the indorsement, and this though the holder had at the time of the transfer to him no knowledge of the indorser's insanity. {Am. & Eng. EneyclopcuJia, vol. xi., p. 144.) INSANITY AND CEIME. BY B. SACHS, M.D. A FEW years ag"o the writer of this article was discussing with one of the learned judges of the Superior Court of New York the question of the responsibility of the insane. The writer stated his opinion that up to the present time the legal tests of insanity, as accepted in many of our States and in England, were entirely unsatisfactory. The judge dissented from this view and thought the matter a very simple one. " All we have to do/' said he, " is to determine whether the accused at the time he committed the crime was able to distinguish between right and wrong, and if he knew that what he had committed was wrong he was as responsible for that crime as any sane person would be.-' Very few legal minds have been able to get beyond this antiquated view of the relation of insanity to crime. In Germany and France the more enhghtened judges have been guided by the opinion of medical experts, but even there they are not in anywise bound by such an opin- ion, and it has happened again and again that the judge, having asked for and received the opinion of medical experts, has promptly set it aside and decided the cpiestion to the contrary. In England and in this coimtry, unfortunately, the cpiestion of insan- ity, and of mental resjionsibility for crimes committed, is referred to a lay jury. Judges and laymen acqinesce in the behef that a l.^ody of twelve, often ignorant men, can decide the question of mental responsi- bility, which under favorable circumstances may baffle the ingenuity of the most conscientious medical expert. England and America have been under the intluence of the decision which the English judges gave in answer to certain questions which were propounded to them hj the House of Lords in 1843, after the atrocious nnirder of Mr. Drummond by McNaughton. Maudsley, whom I follow in this matter, summa- rizes the answer as follows: "To establish a defense on the grounds of insanity it must be clearly proved that at the time of committing the act the party accused was laboring 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, if he did know it, that he did not know he was doing what was A^•l•ong." It vn.\l be seen from this quotation that the accused person was not expected to be able to distinguish between right and wrong in general, but that he was at least to know whether the special act M-hich he committed was right or wrong, or that he Avas to be entirely ignorant of the nature of the crime committed. This "right" or "wrong'' test has been the stumbling-block in the advance of 175 176 -4 SYSTEM OF LEGAL MEDICINE. legal psycliiatiy, and, as a matter of fact, if tlie test liere mentioned were to be applied to the insane, nine out of every ten Innatics would have to be declared sane, for most of them are perfectly awai-e of the nature of the acts they commit. The majority of them know that they are right or T^^'ong according to the ordinary standards, but they are impelled either hj sudden influences or b^' sudden forcible delusions to the commission of acts which they know to be A^Tong, and which, if sane, they would never have committed. We shall have occasion to refer to this question in detail ; for the present it suffices to point out the difficulties met with in determining the relation of insanity to crime. These difficulties have been increased by various unfortunate cn'cumstanees : first of all, the plea of insanity has been frequently used in cases in which there was not the least excuse for advancing it, and it w^as put forth simpl}^ in the hope of deluding the lay juiy. The plea, therefore, has fallen into discredit, and the sus- picion is entertained in almost every case in which the plea is advanced, that it is simply a lawj^er's trick and nothing more. Yet if one were to take the entire criminal history of this country into account, I feel satisfied that many more insane have been j)unished for crimes for which they were not responsible than sane persons have escaped the just penalty of theii' crimes on the plea of insanity. In this connection it is interesting to note how much more frequent insanity is in the criminal classes than in the normal population. Allow- ing for the number of cases brought on by imprisonment, the statistics still point to the close relationship) between insanity and crime. Accord- ing to Thomson, twelve percent, of prisoners in Scotland were insane. Of 5432 prisoners, 673 were insane ; of these 57 were imbeciles and 57 were epileptics ; but of the total number only 53 were declared insane at the time they were sentenced. In England and Wales there is one luna- tic to every 432 free inhabitants ; but among 664 accused of murder from 1857 to 1867, 108 were insane. (See Baer, Der Verhrecher, 1893, p. 258.) In this country Dr. Robinson, physician to the Eastern State Peniten- tiary in Pennsylvania, states that in five years he has had to deal with about 3500 convicts for periods of one year to five years ; of these 245 were insane upon reception, 40 had insanity de^^elop during theii' incar- ceration, and 20 were guilty of simulating insanity. In a paper read in Washington in 1892, Dr. Allison tabulates the crimes committed by 87 court cases now in the New York State Asylum for Insane Cruninals. Murder 38 Assaults in the fii'st degi'ee and attempts to kill 18 Dangerous assaults 10 Arson and attempt at arson 8 Burglary and larceny 10 Bigamy 1 Horse-stealing 1 Disorderly 1 Total 87 Another difficulty that besets the question is one that should be seri- ously considered. The layman argues that it is all very well for medical men and for sentimentalists to excuse crime on the plea of insanity, but JNSANirr AM) CRIME. 177 wliat is society to do in order to protect itself apfainst the crimes of tlie insane f As medical men we are l)ound to defend tlie i-i<^hts of the in- sane, but as mendjers of society we must a(!knovvl(Mlo-e that the latter has full rig'hts, and that it should enjoy imnninity from crimes due to dis- eased nunds. A remedy must be soug-ht for the protection of society, and this remedy is not only the establishment of asylums for the ci-imiual insane, l)ut also the retention of lunatics who have committed crimes in such asylums for years, if not for the remainder of their lives, or at least until the daiig'er of their committing simihir crimes has passed. In a recent trial in this city the experts did well who urg'cd that a woman who was declared innocent of the crime of murdering her children should not be allowed to go scot-free, but that she should l)e sent to an asylum and her mental condition carefully watched. Society must iind some means of protecting itself, but it should not be guilty of judicial murder. The national conscience is no longer responsible for the execution of witches, for the torture of those who were supposed to be possessed of the devil, but it has until recent years been responsible for the death of assassins whose deeds, as in the case of Guiteau, for instance, Avere clearly the result of mental aberration. Let society proceed with all due rigor against those who are the instigators of crime ; let it adopt the most strenuous measures against anarchists and other enemies of societ}' whose revolutionary doctrines generally supply the torch that was needed to excite weakened and diseased minds to the commission of outrageous crimes; but let the poor unfortunate lunatic or iml)ecilewho has yielded to anarchistic preachings or to the impulses of his morbid mind not suffer the x)enalty of a crime for which he is iu)t responsible. The (piestion arises. When shall the plea of insanity be considered valid in extenuation of crime "? The only proper answer to this question, in the light of the present condition of psychiatry, is that no xjerson filiall he considered guilty of a crime if, at the time the crime ivas committed, he was snferiuf/ from any form of mental disease. The medical expert should be called upon to state whether the person accused is or Avas sane or insane, and if insane he should not be held resiionsil;)le for his acts. In several recent trials in this country the question has been put in this broad wa}^, and the answei-s of the exi)erts have l)een accepted Avithout any reference to the older legal tests of responsil)ilit3'. Let the medical man's duties also end with the determination of this purely medical ques- tion, and let the law and its exponents accept the responsibility for everything else. But in order that the question of sanity or insanity shall be justly decided, it is necessary that the opinion shall be expressed by those avIio are truly (pialified to give an opinion. Psychiatry is a veiy special bi-anch of medicine. It does not con- stitute part of the regular medical training in this country or in Europe; yet in some of the most important trials of recent years any medical man has been accepted as expert, and his opinions Iuxa'C been held to be fully as valuable as those of a man Avho has deA'oted years to the study and practice of this special branch. There is no more reason to accept the opinions of a gynecologist in questions of insanity than there Avould be in accepting the opinions of an alienist on the feasibilit.y of an operation upon the eye or the removal of an abdominal tumor. But if the expert has been ])ro])erly chosen another refm-m in the nu^th- ods of medico-legal procedure is urgently called for : the expert should 178 -4 SYSTEM OF LEGAL MEDICINE. not be made a partisan to one side or the other, but the facts should be submitted to him as imjDartiall}^ as possible, and he should determine the question of sanity or insanity after considering such facts, and, if possible, after an unprejudiced examination of the supposed criminal* In spite of all the defects of com*t procedure in the United States in matters affecting insanity, it is a satisfaction to know that the riUings of the more enlightened judges in this country indicate a decided advance upon the princij)les laid down by the English coiu'ts. In the State of New York the statutes simply state that "No act done by a person in a state of insanity can be punished as an offense." The humane spirit of this statute cannot be denied, and it will be noted that nothing is said in it of the responsibility of the criminal in case he was able to decide between the right and the Avrong of the act he committed, whether he knew or did not know that it was contrary to the law of the land, or whether the act was the natural outcome of his insane impulses or his insane delusions. The fact to be determined is simply whether the per- son accused is sane or insane, and if insane, whatever the form of insan- ity may be, he is not resjDonsible for the deed committed. The spirit of this statute throws greater res]3onsibihty upon the medical expert. The principle of the statute of the State of New York is not yet adopted by all other States of the Union, and is very far from being adopted in England. We must therefore still discuss, though we may do it more briefly, the older tests of responsibility, and determine to what extent a person may be liable for acts he has committed.! In Germany the law revolves upon the j)oint that the sane individual has free will, and if by reason of disease the free exercise of the will is precluded the person cannot be held responsible for the acts committed. The New York statute is evidently superior to this, for to decide simply upon the free determination of the wiU involves a great many diificul- ties, above all that of proving to judge and jury that the person in ques- tion could not exercise his own free will, and that such exercise was in any way influenced by the delusions or other symptoms exhibited by the accused. It leaves out of consideration altogether the question of violent acts due to sudden morbid impulses, and it requires the applica- tion of sane reasoning with regard to insane delusions and impulses. The English courts seem to be bound more than all others by ancient precedent, and in spite of vigorous protests by eminent English jurists and many eminent medical men the old order of things still obtains. It is fair to say that more judicial murders are committed in enlightened * For a fuller discussion of the evils attending the methods of eliciting medical- expert testimony the reader is referred to a short article by the present writer in the Medical Examiner for July, 1892. t The " right and the wrong " in law, the tolerant and the intolerant spirit, are well illustrated by two judges' charges. In the case of Stevens vs. State (see Lawson, pp. 88 et seq.). " If the jury believe from the evidence that the defendant knew the difference between right and wrong in respect to the act in question [murder] ; if he was conscious that such act was one which he ought not to do ; and if that act, at the same time, was contrary to the law of the State, then he is responsible for his act." Contrast with this nai-row view the charge of Chief-Justice Perley, who instructed the jury " that the verdict should be not guilty by reason of insanity, if the killing was the offspring or product nf mental disease in the defendant; that neither delusion nor knowledge of right and wrong, nor design or cunning in planning and executing the killing and escaping is, as a matter of law, a test of mental disease, but is purely a matter of fact to be determined by the jury." IXSJXITY AXD CRIME. I79 England tliaii iu any other country of the ci\'ilizo(l world* English judj;es iind those who are inclined to follow them in this country — and many do — still fall back upon the simple test of whether the accused at the time of committing- the act was able to distinguish between the rig:ht and Avrong' of it, and if he was so al>le to distinguish he is as res])onsible for the act as though he were entirely saiu'. There are relatively few luna- tics who commit violent acts who are not aware at the time tlicy commit the act that it is wrong, but their judgment is befogged for the time being, the motives which impel them are different from those which guide the sane, their passions are more uncontrollable, and they often act in obedience to delusions which impel them to commit deeds which they know to be wrong, and which nuiy be as abhorrent to them as they are to others. Many an insane individual has repented an atrocious crime the very next moment after he had committed it. It was clear to the English judges that the "right'' or "A\Tong" test could not be upheld in every instance, and for that reason further rulings were necessarily made with reference to the influence of insane delusions, insane motives and impulses ; and iu making such rulings they have revealed a deplorable ignorance of the peculiar changes which the mind undergoes in disease. Thus the judges declare, in answer to the question whether a person who, under an insane delusion as to existing facts, commits an offense iu con- sequence thereof, should thereby be excused, that such a person must be considered as responsible as if the facts of the delusion were real ; and they state furthermore that if a person under the influence of a delusion supposed another man to be in the act of attempting to take his life, and killed that man in self-defense, such person would be exempt from punish- ment. But if he was suffering from a delusion that another had inflicted serious injury to his character and fortune, and he killed him in revenge for such supposed injury, he would be liable to punishment. Nothing more absurd than this has &yev been "s^i-itten by a sane mind. A person who has an insane delusion is expected to be able to reason regartling the facts of the delusion as every sane person would ; he is expected to be guided liy sane motives and to have none but sane im- pulses with reference to his delusion. As Maudsley puts it, " He is ex- pected to be reasonable in his uni-eason, sane iu his insanity." This doctrine is the outcome of the older theories of partial insanities, im- plying that a person could be sane in all other respects while absolutely and hopelessly insane on some one single point of lielief. Modern psy- chiatry has taught us that this older doctrine is wholly untenable, and that the mere continued existence of a single delusion, whatever its char- acter may be, proves that the entire mind is diseased — that the logical faculties, the judgment, and the reason of the person have lieen seriously impaired. If we consider, furthermore, that any person atflicted with a single delusion is complete^ dominated by it, the injustice of insisting that he shall be guided by ordinary reasoning will be evident at once. The theory of monomanias has done much mischief in psychiatry, but it has done infinitely more in nu^dical jurisprudence. The English law insisted that the criminal was responsible for his act if he knew that such act was contrary to the law of the land. Tliis * According to tlie Lancet, influential sub-committees of the Br. Medical and of the MtHlico-Psychologieal Associations have been appointed to investigate and report upon this subject. 180 ^ SYSTEM OF LEGAL MEDICINE. was a departure from tlie strict "right" or "wrong" test, for iu many an instance the insane are thoroughly cognizant of the law of the land and vet hold a very diifereut opinion as to right and wrong in obedience to their own delusions. We need not enter into further argument regard- ing this older test. It is conceded on all sides that the insane may have a perfect knowledge of right and wrong at the time a criminal act is committed and yet not be responsible for the act. The influence of de- lusions is also liberally conceded, but much more difficulty is encountered in the attempt to represent to judge and jury that the motives of the insane are very different from those of persons with healthy minds, and that sudden morbid impulses are responsible for many acts of violence. Let us take up the matter of the motives of the insane as a guide to- action. Persons in good mental health are expected to be guided by the exercise of their own judgments, by their* own and the accumulated ex- perience of others, before proceeding to any rash act; and in addition tO' this the fear of punishment is supposed to exercise a very powerful, de- terring influence. A sane person is excused for an act of violence only on the ground of self'-defense, and self-defense only in case he is satis- fied that his life is being actually attempted. Feelings of revenge are not allowed as an excuse for criminal acts, and, above all, the sane per- son iu every civilized community is not allowed to take the law into his own hands. The diseased mind loses sight, however, of all these restrain- ing influences ; the judgment of the insane individual becomes defective,, and his reasoning is warped by the presence of delusions and by the change iu his temperament. There is httle difficulty, as a rule, in excus- ing crime that is the direct result of a delusion. Any jury will exempt the accused person from punishment if his acts followed as naturally upon the delusion as they would in sane persons if the facts of the delu- sion were real. But trouble is certain to arise whenever the motives lead- ing to an insane act are unknown or do not appear to be the direct result of a delusion. There is the famous story of the boy who was extremely fond of windmills. He was sent far away from his home for the improve- ment of his health ; while away he induced a little girl to go with him to the woods, and there committed a brutal murder. He surrendered himself at once to the proper authorities, and when asked why he had committed the crime his reason wa,s one which few would have surniised. He was anxious to see the windmills, and he knew that after committing an act of this sort he would be returned to his own birthplace, where his desire for whidmills would be fully gratified. Could any sane mind have suspected such a motive? What an unbalancing of all mental facul- ties this implies ! Take the case related by Dufour : A paranoiac was anxious to flee to America to escape from supposed enemies. Having no monej^ he decided to murder and rob a rich old couple. He bought a hammer, blackened his face, and l)ought a linen blouse to cover his clothes and keep them from becoming blood-stained. In this there was ' premeditation and a desire to conceal liis person, also a knowledge of the wrong done ; but marked insanity withal. Among jurists and medical men there has been some hesitation in allowing for the effect of siidden morbid impulses. The plea of insanity has in such instances been taken to be a mere subterfuge. It is claimed that even among the sane sudden impulses are common enough, and that if every sane individual were to act upon the numerous impiilses starting INSANITY AND CRIME. 181 up witliin him, he too might be guilty of criminal acts. The very sud- denness of the impulses in the insane, the fact that the impulses cannot he subdued, that the person nnist act upon it, constitute the strongest proof that sueli impulses are the <)ffs})ring of a diseased mind. It is a mistake to think, furthermore, that the insane yield to their impulses without any attempt at self-restraint. Were this true we should have dozens of suicides and homicides for every one that actually occurs. I have always felt how true Meynert's remark was which he made vei-ljally to his students on one of his rounds : " Considering the delusions, the impulses, and the passions of the insane, there is more self-restraint in- side an asylum than there is outside of it." Every one of us has been witness to the struggle which those who are permanently or temporarily deranged have made in order to resist the sudden impulses coming over them. At some time a limit of endurance is reached, and, unfortunately, the insane individual has to yield to the sudd(ni impidses urging him on to commit every possil)le form of crime. Tlie laity and many medical men may claim that since the person in question and since others have been known at various times to resist morbid imj)ulses, it was his duty on this special occasion again to resist. We may consider it unfortunate that he was not able to do so, but can surely not hold him resj^onsible for yielding to impulses which were so strong as to control his entire being. The criminal act is the natural result of his mental condition, the natural outcome of mental disease, and that must decide the lack of re- sponsibility, while there is room for congratulation that the accused and others so often I'csist the sudden biddings of an impidse. I grant that there are great difficulties in the way of accepting this theory of morbid impulses as a defense for criminal acts. It may be urged that every act is the result of a sudden impulse, and that if we alloAv the defense in one instance we must accept it in all. To avoid this dilemma it is only fair to expect that some other signs of mental derangement shall be discovered in a person who has yielded to a ]norl)id impulse, or that proof shall be forthcoming that the person has had pi-e- vious impulses of this kind to which he has unfortunately yielded. If such evidence is not easy to procm*e, further observation of the accused individual should supply the necessary evidence as to his mental condi- tion. It may be urged, on the other hand, that the impulse which led to the commission of the crime was the first and onhj impuhe of the sort ; that with the exception of this " temporary fit of insanity," as it is j)opu- lai'ly called, the person is entirely sane. I am not willing to give my approval to such an argument, for, as a matter of fact, single impulses of this description are very rare indeed, and if the person is kept under proper ol)servation further evidence will sui-ely be found. It is interesting to note the relation which these morbid impulses hold to conditions occurring during normal life. Every one has turned out the light in his bedroom, and has been suddenly seized by the fear that the light was not properly turned out and that the gas might be escaping. He gets up, finds he is mistaken, goes to bed. and after a few niinutes may be stai-tled again l>y the same fear. "Uliat has hap- pened to him is tliat a sudden morlud conception arises in his mind as to the escape of gas, and he is not al)le to allay the fear by the methods which ordinarily carry conviction. Returning to one's door again and again in order to make sure that it is properly locked : the fear that the letter which has just been mailed was not properly sealed ; or the fear Ig2 A SYSTEM OF LEGAL MEDICINE. that one forgot to sign a letter or a check — all sncli imperative concep- tions are of daily occuiTence in the hte of health}- indi^'id^als, are often regarded as annoying occurrences, but that is about all. If we carry this physiological oceui-rence just one step further the morbid conceptions may become i>ermanently lodged in the mmd and may lead to morbid impulses. Who has not felt when standing on a giddy height that he would be suddenly drawn into the abyss below, and for fear that he might peld to this feehng has stepped back a safe distance from the abyss ? ' Others on board a vessel have felt suddenly a peculiar sensation, as "^ though they would be inevitably di-agged into the water; they step back unconsciously in order not to give way to this special impulse. At the sight of a knife many a person has felt that he or she might do some harm \\ith such a weapon. A few j^ears ago an unhappy woman came to my clinic, and stated that whenever she sat down to table with her husband and her five-year-old child, whom she dearly loved, she felt as though she would have to seize the knife and kill the child. She stated that she passed through the most intense agony, for she would not wilhngly harm a hair on the child's head. She came to me begging for advdce what to do. I told her that she must, of course, control her- seK under all circumstances, but that it would Ije advisable for her to separate for some length of time from her child, to which she readily consented. A few weeks later she ajtpeared again, stating that now that her child was away she had exactty the same feelings with regard to her husband, and that unless she were placed under restraint she would some day kill him. Husband and vvif e too had to lie separated, but wheth- er they were ever reunited, or whether the poor woman has committed some act of violence in obedience to her impulses, I cannot say. Few sane people would control themselves as this woman did had they similar impulses. AVho would blame such an unfortunate creature if at such times she had vielded to the promptings of her diseased mind ? There is a stoiy, also, of a nurse who was attending a child of Alexander von HumbVjldt, who begged to be dismissed from service because every time she bathed the child' and saw its pm-e-white skin she felt impelled to do it some harm. How closely akin to this state is the entirely normal con- dition of people who, in hugging a little child, feel as though they could bite a bit of its cheek ! We need not refer, in addition, to the innumer- able variations of this sudden play of the morbid impulses, to the sudden feelings or impulses arising in husband or wife as a result of conceptions suggesting the need of the immediate death of the life-partner. The important point to be remembered is that morbid impulses constitute a very grave series of symptoms; that they occm* in different forms of in- sanity, as we shall see later ; and that far from being a mere subterfuge as a defense for crime they are too often the actual cause of the worst outrages. Tlie ei-iminal lunatic does not commit crimes merely as a result of delusions, hallucinations, or morbid impulses. He may have inherited insane tendencies ; his nature may be perverse, degenerate ; he has been reared in crime, and his wrong-doing is inevitable. This is pai-ticularly true of those exliibiting marked moral defects. In these individuals the relation between hereditary mental disease and crime becomes a very close one. The Italian school of criminologists, under the able leader- ship of Lombroso, has devoted much labor to the elucidation of this PLATE II.* — «£^7 Fig. A. Fig. B. Fig. C. Fig. D. CRIMINALS WHO HAVE BECOME INSAXE ("DEGENERATE TYPE"). Fig. A. — Aged .50 years: "Frenchy:"" murder in the second degree: killed "Old Shake- •speare' ' ; asjTiiinetry of head and face ; deep orbital arch ; large ears. Became melancholy and emotional. Fig. B. — Aged 29 years: "instinctive criminal :*" several convictions: had sti'ong delusions ;ind hallucinations: assaulted fellow-convicts. Small head: large lower jaw. Fig. C— Aged 24 years: murder in the first degree: said to have been .insane previously; claims homicide in self-defense. Delusions of persecution. Dolichocephalus. Fig. D.— Aged 31 years: repeated convictions for larceny and assault. Has auditory and '.isual hallucinations ; lower jaw massive : head small. * [The illustrations on Plates II. and III. are of inmates of !Matteawan State Hospital of Criminal Insane, from photographs kindly furnished by Dr. Allison. Superintendent, and Dr. Robert B. Lamb. The author is also indebted to the courtesy of Dr. Carlos F. MacDonald.] lyiSjyjTY AND ciiiMi':. 183 question, ondeavoriiiGf to pi-ovo, by carefnl craniometrinal measnremeiit, abuorinalities of the criminal skull, of the face, and of the entire organ- ism, that the criminal bears the distinct signs of deficient mental and physical endowment. He is a degenerate individual, and if his degen- eracy is not the equivalent of insanity it is at least next of kin to it. The new school has not adojjted the phrenology of Gall, it has not as- signed to various parts of the skull the various peculiarities, vices, and virtues of the individual, l)ut it has endeavored to show that tlie skull capacity as a whole is deficient, or that the frontal region, which is gen- erally considered to be the chief seat of intelligence, is deficient in the criminal classes. But this same region is deficient in other individuals who may lack intelligence but are not in any sense criminal. It is surely wrong to claim that every criminal is insane, temporarily or perma- nently, or to claim the existence of insanity in a crindnal, unless there be some further evidence of insanity in addition to the crime committed. Lombroso in Italy and Benedikt in Vienna have been the chief stu- dents of cephalometric measurenu^nts. I append one table taken from Lombroso's work, showing the varying capacity of criminal skulls and those of insane or epileptic individuals. Skull Capacity. Murderers. Thieves. Sane. Insane. Epileptic. Cubic centimeters. (o) (O Qi) (%) (%) 1101-1150 2.9 0.5 1151-1200 11.7 0.9 1 1201-1250 1.7 3 1251-1300 11.3 2.9 4.3 3 2.0 1301-1350 9.4 11.7 6.9 10 1.0 1351-1400 16.9 11.7 12.9 8 7.2 1401-1450 11.3 11.7 12.9 22 8.8 1451-1500 15.0 17.6 15.5 12 14.4 1501-1550 5.4 17.6 14.6 12 20.1 1551-1600 11.3 8.6 1-1.2 11 16.1 1601-1650 13.2 9.5 10 11.3 1651-1700 5.4 2.9 5.2 2 11.9 1701-1750 3.4 4 3.62 1751-lSOO 0.9 1 1.52 1801-2000 1 2.59 Lombroso draws the conclusion that the skull capacity of criminals is less than that of normal individuals, and that this diminution is much more marked among thieves than murderers ; from which we might infer that murderers are more highly organized individuals than thieves. In skull measurements the criminal (according to Lombroso) is nearer the insane than the healthy individual. But such statistics should not be overstated ; the variations may indicate a generally defecti\"e organ- ism, and in the individual case variations from the average cannot be depended upon as evidences of an insane temperament in its relation to the crime committed. Benedikt, who has examined a large number of Crerman criminals, concludes that in central Europe the army of criudnals is recruited fi'om the lower anthropological order of the various races.* * The present writer lias been tempted to enter iipou the question of the degen- eracy of the " instinctive " criminal, but it would have been aside from the main sub- ject. WhiU^ there is littU' doiiltt tliat the Italian school has exceeded the warrant of its facts in establishing: various criminal types and in attaching undue im])ortance to signs of degeneracy in the individual, it has established for all times the intimate relations 184 A SYSTEM OF LEGAL MEDICINE. "Witliont reference to couflicting theories it will be well to study care- fully aud soberly the forms of insanity which are known to lead fre- quently to the commission of crime. SPECIAL FORMS OF INSANITY IN THEIR RELATION TO CRBIE * Crime may result from defective development as well as from disease of the mind. From a practical standpoint it matters httle whether the symptoms exhibited in a given case, or the actions committed, are due to improper gi'owth of brain (and mind) or to actual disease of a brain that was once normal. Both forms are morbid in the sense that they indicate a departui'e from the normal. But as the brain and the men- tal faculties are not fully developed until the age of puberty has been long passed, we must also include the consideration of those crimes which are the result of unripe judg- ment rather than of disease ; but as a matter of fact very few youthful persons are guilty of violent or wrong acts unless they bear the germs of impending insanity or the traces of a tainted family record. Persons cannot be held respon- sible for criminal acts — 1. If they have not yet attained the age at which they can be expected to realize the full import of their ac- tions, although they may appear to be capable of such development later on. 2. If they give evidence of ar- rested or defective development of the brain (idiocy and imbecility). 3. If they exhibit evidence of such disease of the mind as affects the fully developed brain, or of conditions of degeneration that become apparent only after body and mind have matured. 4. If at the time of the commission of crime they were in an uncon- scious condition or in a state of altered consciousness. I'/ ' ^ ^ V -J Fig. 25. — Ravachol: asymmetry of face, deviation of nose, slight growth of beard, and firmly set jaws. THE RESPONSIBILITY OF CHILDREN. The law of every land concedes that a child cannot be held respon- sible for criminal actions : its judgment is defective, and it does not between the habitual criminal and the insane. The annexed faces will suffice to prove the existence of the insane type among criminals ; but if any reader will take the trouble to consult Byrnes's Frofcmonal Criminals of America, he will find that the majority of tliose habitual criminals exhibit few, if any, signs of degeneracy. For the present there is still a wide gap between criminality and insanity. The entire ques- tion is cleverly dealt with in the book by Havelock Ellis entitled The Criminal. The conclusions of the Italian school of criminology are also criticised in the work of Baer and in the monogi-aph of Hirsch. * For a fuller account of each form the reader is referred to Dr. Hamilton's article in this volume. IXSJNITY AXD CHIME. 185 realize its relations to the other elements of the social organism; it may be able to diseriniinate between right and wrong in certain con- crete instances, bnt of the abstract principle of right and wrong it has no conception. The early acqnisition of snch knowledge is, however, the main object of aU training. The limit of cliildliood is fixed ditferently in various countries. In this country responsibility begins with the foiu-teenth year. Lord Hale demanded that a normal individual should have the understanding. " as ordinarily a child of fourteen years hath." Austria adheres to the same Fig. 26. -Forger : receding forehead and prognatliism. Fig. .—Bandit : receding foi'ehead and liuge lower jaw. limit, while Germany exacts full responsibility after the completion of the twelfth year ; in France there is no well-defined age-limit, and ehil- di'cn under ten are not infrequently brought to court and sentenced. In all civilized countries there is a tendency, however, to extend the limit ; in France to the age of sixteen years or thereabout, and in other coun- tries even up to the age of eighteen years. This is quite in keeping with the efforts at criminal reform, and special reformatory institutions have been established at different places for the care and reform of youthful dehnquents. Among the general average of youthful criminals not a few show signs of a bad inheritance. The statistics of early crimes are quite appalling, showing the need of special legislation ; according to Krafft-Ebing the average number of criminals under sixteen years in Prussia varies between 5085 and 9225. A very few only of these youthful criminals are examined ■^^dth reference to their mental condition ; if such an exaniination were made it is safe to say that a very large number would give undoubted evidence of de- fective inheritance, or of deficient mental and moral training in early years. And this deficiency in training is often in direct relation to the mental peculiarities of parents. Several of the worst cases at the Elmira Reformatory have been boys w^ho were supposed to be of normal mental development, even bright ; yet their descent from hysterical and epileptic stock, and the poor training which neurotic parents gave them, were 186 A SYSTEM OF LEGAL MEDICINE. Fig. 28. Fig. 29. Fig. 30. Fig. 31. Fig. 33. Fig. 33. Figs. 28 to 33.— Selections from sketches made by Dr. Vaias Clarke of Woking Prison, and re- produced in Ellis' book. Fig. 28.— Dock laborer, aged 18: assault and robbery. Fig. 29.— Farm laborer, aged 38 : hprse- tbief. Fig. 30.— Laborer, aged ,21 : robbery with ^^olence. Fig. 31.— Puddler, aged 21 : wounding. Fig. 32.— Cook and steward: larceny. Fig. 33.— Age 25: robbery with violence. AU but one (Fig. 31).-had been previously convicted. PLATE III. j f } ■Jii-. A. Fit?. B. Fi>,'- C. Fii,'. I). CFvIMIXALS BY REASON OF INSANITY. FiK. A.— Aged 37 years; killed Dr. Lloyd, a.sylum physician: in love with Mary Anderson: declared "insane and" responsible '"(1); life sentence. Characteristic pose of body. Fiii. B.— Aged .50 years; insane ancestry; impulses to kill his children; murdered a police- man without cause. Hallucinations and delusions; "can talk with mice, birds," etc. ; melan- choly countenance. TJ! • Fig. C— Aged 26 years; murder in the first degree: sentence commuted to life imprison- ment; one terra at reformatory; insane ancestry. Is depressed: delusions of persecution; massive jaws; dolichocephalic; exophthalmos: coronal suture depressed. Fig. b.— Aged Cn ; shot at a female church-organist. Hallucinations of hearing caused act. lity not recognized on trial. Says he is "Duke of Sussex and Earl of Beauharnais. Insanity INSAXITY AND CBIME. 187 directly responsible for the wrongs they committed * Growing np amid such surroundings they could not bo expected to discriminate between right and wrong in the abstract, nor even between mine and thine. Consider in addition that the age of puberty is attended by an awak- ening of the sexual sphere, with all that it implies regarding the relation to the opposite sex — a period fraught with a certain amount of danger for every normal child ; consider, also, that at this same age all the latent inheritance conu's into play, that the family ghosts (hysteria, epilepsy, insanity) have their say, and that the hal)it of mastui-bation is often engendered to intensity latent defects or create new troubles : consider all this and there will be little wonder that crime is so frequent in early life. Children have committed many different crimes. Murder, arson, and stealing are tlie comnu)nest of these, all of them the result of defective judgment or of defective training, or both. S., a lad of ten years, living in Alsace, had a compauion who, as the son of wealthy parents, wore fine clothes. S. was envious of these. One day he induced his little friend to go to the woods, murdered him, and then donned his fine clothes, leaving his own ragged clothes at the place of nuirder. He was discovered and tried. The jury found that he acted with " discernment," and declared him guilty, but recommended him to the mercy of the court; he was sentenced to ten years in prison. (Mit- termaier, Friedreich's liJaffer, 1865, vol. v., quoted by Krafft-Ebiug.) The jury were evidently guided by the old principle that if the person knows the nature of the act he must be guilty. This does not hold good with reference to adults ; applied to a child of ten years it is monstrous. Last year a boy of twelve years was brought to me from Texas, who had been placed at a school away from home and lived with one of his teachers. This was evidently not to his liking. One evening he asked to be allowed to attend a '"' candy-pidl." The teacher refused. Very soon thereafter the boy walked into his bedroom ami deliberately set fu-e to the clothes in a closet. As soon as the smoke was noticed he confessed what he had done and helped to extinguish the flames. The examination of the boy brought out the fact that he was not very l)riglit, and that he was homesick ; and that he committed the act first from a slight feeling of spite toward the teacher and then because he was anxious to be sent home. During a prolonged period of observation and for months at home he has not shown any evidence of insanity or of viciousness. Still another case will illustrate the narrow line of demarkation be- tAveen sanity and insanity in children, as well as the effects of faulty training. A well-developed girl of fourteen, the child of respecta])le and well-meaning parents, was referred to me some tinu' ago for an 0})inion as to her mental status. The child had become Avillful and unmanage- able, had no regard for the truth, and at school had taken things out of other children's pockets. In addition to these unfortunate qualities she exhibited considerable sexual excitement and was anxious to obtain in- formation on sexual matters. By her relatives she was supposed to be precocious, whic^h she was not except as regards vicious habits. In former days physicians would have made a diagnosis of kleptonuinia, if * In this respect the medical reports of the Elmira Eeformatory are of great in- terest. 188 ^ STSTE^r OF LEGAL MEDICLXE. not of moral insanity ; bnt the cliild, ttIio was descended from a distinctlj^ nem-otic stock, was the victim of f aiiltr training : in view of her snpposed precocity she was enconi-aged in the' idea that what she desired should be hers, "that she was an imusnal child, etc. This young gii"l was placed in the charge of an intelligent, sober-minded teacher, who has studied her mental peculiarities and has succeeded in changing the child's point of ^dew. In this one instance the cooperation of physician and teacher has averted impending mischief : but in dozens of other cases the seed that has been sown ripens, and aU sorts of crime result in later years fi-om faulty inheritance made worse by faulty training. The inference to be di-awn fi'om 'these few examples is that even if insanitv cannot be proved in a youthful criminal, the antecedent history and the early education of the child should be taken into account, and both these may discover extenuating cii'cumstances. AEEESTED OR DEFECTIVE DE'S'ELOPJMENT OF THE BRAIN. Under this heading are to be included all cases of insufficient devel- opment of the mind varying between idiocy, imbecihty, and mere weak- mindedness. This is a difference in degree and not in kind 5 a difference in the stage at which cerebral development was arrested, or a difference in the extent to which the development of an imperfectly organized brain has been carried. Idiocy or imbecihty may be truly hereditary, or due to injmy dming labor, or' to influences which have been active during the earlier years of life. Idiocy fi'om hereditary causes is most apt to occm- iu the descend- ants of distinctly nem-otic stock, in families in which insanity has occm-red in succeeding generations, or in those in which epilepsy, chorea, hysteria have been fi-equent occm-rences : often the parents themselves have been thus affected. But two conditions lead more frequently than all others to idiocy and imbecility in the descendants : the fii-st is alcoholism of either parent,* and the second is blood-relationship between man and wife : it' there he the slightest taint in the family this taint is greatly in- tensified by such a imion. As there are few families entirely free from such taints, the e^il of intermarriages -can be easily gauged. A vers' considerable numlier of cases of idiocy are dne to diSiciilties dm-ing labor. To the .study of this class of subjects the present wiiter has devoted much tune and lalwr. The purely medical questions in- volved need not lie alluded to in this chapter, but fi'om a forensic point of viev: it is important to know that prolonged labor and the application of the forceps to the skull of the child often cause a hemorrhage over one or both halves of the brain ; that this hemori-liage ultmiately results in an atrophy of a considerable portion of the cortex ; and that this at- rophy may lead to defective development of the mind. Let me add at once'that'the law;s'er and medical man should not endeavor to prove too much by this, for in the vast majority of cases prolonged labor and in- stinimeiital delivery do little harm ; and if harm has been done to the \>Y-Am>pUq)sy and jxtrahfsis (unilateral or bilateral) are frequently associ- ated u-ith idiocy or imbecility. Idiocy or imbecility may also be due to external injmy (falls) to the skiill during the early years, or to the acute infectious diseases so com- mon in chiidliood. Convidsions, whether of reflex origin or the precur- * Syphilis is also mentioned by many, but I doubt its significance in tins respect. INSANITY AND CRIME. Jgg sors of an infectious disease, may be the direct cause of arrest of brain development. I have known children of two years and even older to become complete idiots after the occurrence of such convulsions, alth(High they were entirely normal ])efore such convuLsi(»ns had occurred. Fiu'thermore, weak-mindedness developing- at aljout the ajj^e of pu- berty nuiy l)e the result of inheritance; in these cases the brain has Ix-en capal)le of a certiiin amount of development, and the symptoms of imbe. cility have not become manifest until the work of a normal adult brain has been expected. The jurist and the medico-legal expert need take but little trouble to prove the existence of idioc}^ : the idiot, as a rule, speaks for himself ; but there are grades of imbecility wliich approximate so closely to the normal tlia.t it will require some skill to demonstrate wherein the imbe- cile is deficient. The idiot is entirely incapable of utilizing impressions that he has received ; there may be perception, but not apperception ; he is restless, but restless without a purpose ; he is animal-like in his appetites, and the gratification of these is sought, at times, in bestial fashion. It is needless to add that the idiot exhibits no judgment and no memory, ex- cept that he is veiy apt to know whether his appetites have been gratified in the usual way. The imbecile is distinctly removed from this order of beings, yet re- lated to them clearly enough. He is capable of a few al^stract concep- tions, may learn to know liis relations, can be taught to avoid danger, to keep himself clean, to be quiet when strangers are around, and so on ; but as he grows the deficiency of his mental and moral make-up is evidenced in the excessive development of the animal appetites. The gratification of hunger and of the sexual appetite is his most important aim in life. Every one has known imbeciles who coidd be made happy l)y tobacco or a few drops of whiskey. The sexual appetite is gratified by self-abuse, which soon increases the imbecility, or l)y attempts at in- tercourse with all sorts of persons — mth children and old women ; Giraud reports [Ann. Med.-Psuch., 1885, vol. i.) the case of an idiot who attempted to rape his own sister. A feeling of modesty or of shame is, as a rule, entirely wanting. When all symptoms are distinctly marked the task of diagnosticating imbecility is relatively easy. It is much more difficult if the person in question exhibits only a moderate degree of iml)ecility ; in such cases we must be guided entirely by an examination ^\\\h. reference to the range of the person's mental horizon, and 1\y the account (always valuable) of his behavior toward his relatives and in his home surroundings. A com- parison with Other subjects of the same age is important, but individual differences must be allowed for.* The idiot and the imbecile have defective judgment and cannot, there- fore, be held responsible for the acts they commit ; they may learn to distinguish between right and wrong, but they are deficient in the appli- * A few imbeciles liave attained eousiderable skill in some one department, as me- chanics and even as artists ; tlirongh carefnl education the original imbecility may be covered np. Sander reports the case of a young German who passed his first law examination who was pronounced an imbecile. I knew a young t-hemist. an evident imbecile, who had succeeded in passing his examination, but it took him years of study to get what others got in a few years ; in the struggle for existence he proved an absolute failure. 190 A SYSTEM OF LEGAL MEDICINE. cation of sucli knowledge, for their judgment and deficient reasoning are easily overrnled by their passions. Imbeciles have committed crimes not realizing the full consequences of their actions, or from a mere desii-e to gratify their passions and im- pulses. Casper reports the case of an idiotic cannibal of forty years, who was in the habit of carrying about a nephew of two years. One day he failed to return home ; he was discovered in the woods ; he had bit through the child's throat and gullet, had eaten its flesh and drank its blood. His only motive was that he wished to eat the child's flesh in order that he might grow tall — he had no conception of the enormity of his crime. The annals of crime and of psychiatry are full of such cases — none more horrible than that of Carlino Grandi, who buried four children alive, and was discovered when he attempted to bury a fifth. He was anxious to rid himself of boys who were poking fun at him, and thought it quite a proper way to proceed. He thought that the four boys who were in Paradise were better off than he. He was sentenced to impris- onment for twenty years. Imbeciles have so frequently been guilty of incendiarism that they constitute a large percentage of pyromaniacs. The incendiarism is some- times the mere result of a desire to see a grand spectacle, in other cases of a desire to practice revenge upon a supposed rival, and sometimes arises from a mere spirit of restlessness and a desire to do something. Whatever the nature of the crime may be, it is the duty of the medical expert to prove by the history of the accused, and by the result of his examination, that he presents distinct symptoms of defective mental de- velopment. DEAF-JIUTISM. No one would ordinarily think of classifying deaf-mutes with the insane ; but if they have not been trained in special schools they may re- main entirely devoid of all moral concepts, and their social status may be not unlike that of the imbecile or idiot. Fortunately, criminal acts by deaf-mutes are very much rarer than they were, owing to the im- proved methods of instruction. If a deaf-mute commits a crime it will be natural to question his responsibility ; but a decision can under no circumstances be given unless it is clearly proved whether he has or has not been properly trained, and whether his mind has been able to grasp the ordinary conception of right and wrong. No one but an experienced deaf-mute instructor can be trusted to secure such evidence, or to deter- mine the exact condition of his mind. Under the influence of strong emotions during a fit of frenzy, deaf-mutes have set fire to houses and have committed murder. Casper {VierteljahrsscJir., vol. xxii., p. 136) tells of a deaf-mute twenty- four and a half years of age who set fire to a stable after he had been struck by his father, who had been in the halnt of abusing him. Wliile the fii-e was raging he clapped his hands with joy. On examination he was found to be weak-minded, his mental capacity not exceeding that of a boy of fourteen. It is evident that deaf -mutism aloue does not constitute an excuse for crime, but that if the person has not been properly trained his intellect and his moral make-up may be defective. It is therefore of the utmost IX.SAXiry AND CHIME. 191 iiui)ortaiice to determine the exact meutal eouditiou independently of tlie deaf-nuitisni. The condition of deaf-mutism may be simulated; if so, the following tests should be iviiiciiibcrcd : A deaf-nuite perceives the vil)rations of the air caused by h)U(l chipiting of the hands or by stanii)ing the floor; a sinndator will claim not to notice this, nor to perceive the vibrations of a tuning-fork placed between the teeth, which a deaf-mute perceives perfe(;tly. Deaf-mutes spell correctly as a rule, as they have been care- fully instructed ; simulators often spell incorrectly, perhaps intentionally so. ^ Krafft-Ebing refers to a method suggested to him by Professor Kessel. The supposed deaf-mute is to be placed in a room and given his meals at regular intervals. This is to be omitted for once, while in an adjoining room the sound of "forks and knives" is to suggest that it is time for his meal to l)e l)rouglit : he will, in all probability, turn to the source of the noise. This is ingenious, but we doubt whether it will prove successful in all cases. JMELANCHOLIA. Melancholia is a well-recognized form of insanity which may become the cause of crime. It is not to be confounded with simple melancholy depression, which may accompany almost any form of mental disease. It is as natural for a lunatic who has delusions of persecution to be de- pressed and melancholy as it would be for a sane person who found that everything and everyl:)ody were against him. In true melancholia the depression is the primary condition. Without cause or reason the patient is in a state of intense depression, out of which he cannot be argued. Whatever his experiences may be, even though they might have been a source of pleasiu'e to others, he is swayed by the depressed mood, and will look at the world only through the dark- ness of his own soul. His feelings are smothered. He takes no pleasure in business or professional work ; music has lost its charm ; he grows indilferent to every one, cares not for wife or child ; he is doomed to per- dition, and every one dear to him is to meet the same fate. A mother once devoted to her children feels that all maternal feelings have left her ; that she does not care whether her childi-en are ill or well, whether they are living or dead. None but sad thoughts pass through the mind, helping to intensify the original depression. A total lack of energy characterizes such patients ; with this lack of energy goes the idea that there is no use in trying to do anything, for it is bt)und to lead to evil and to do harm in the end. The patient sometimes perceives the slug- gishness of mind and body which is so characteristic of this state, and grows more and more morbid over this altered state of feeling, broods all day long, becomes silent and totally indifferent to everything. The physical depression, the loss of appetite and of sleep, chronic constipa- tion, soon affect his general bodily health, and he becomes a pitiable l)liysical and meutal wreck ; but, fortunately, in many instances the wreck is not complete and recovery may set in. In melancholy there is a distinct inhibition, a '' slowing up " of all men- tal and physical processes, but the person thus afflicted is able for a time, at least, to examine his reasoning poAvers, and will naturally try to find some cause for his depressed feelings. As a ride the cause is supposed 192 ^ SYSTEM OF LEGAL MEDICINE. to be within himself : he has not done his dnty to his next of kin, to his fellow-men ; he feels that he is a miserable creature, that he has been guilty of gi-eat sin, that he does not deserve to live, bringing misery only upon himself and his family. Mothers suffering from melancholy de- clare that they have not done their full duty toward their children ; that they have been neglectful of their children's earl}^ education, or, as a patient of mine insisted, she did not prepare her daughter properly for the duties of married life, aud in this committed a grave otfense — ^in short, naught but self -accusation. To make the condition still more painful, delusions and hallucinations in keeping with the depressed emo- tions add to the anguish of the patient. For weeks and for months the patient may remain in this condition of depression, showing no signs of phj^sical or mental activity, often not uttering a word for days at a time, except possibty to bemoan the sad- ness of his or her fate ; but this quiet is at times changed, and quite suddenly too, and the violence of the acts committed is often in direct proportion to the degree of former depression. The j)atient breaks all chains at once, as it were. The melaucholiac is led to deeds of \dolence in order to put an end to his own sufferings, to avert impending danger for himself and others, or in obedience to delusions and hallucinations. A sudden fear is very apt to seize him, and in tliis condition he becomes thorougiily irrespon- sible. Suicide is the natural effort of the depressed patient to free himself from misery ; but on this act we need not dwell at any length, for it is not a crime in the eyes of the law, and the question of responsibility is not to be argued with regard to it. But cases of " indirect suicide " have occurred which are of the very greatest importance. Religious scruples have prevented many an individual who was so inclined from committing suicide, but as his only wish is to die he must merit death in some form, and so commits miu"der in order that he may be put to death by the State. A young man twenty years of age, without any known cause, stabbed a young woman sitting next to him in the theater ; she died instantly. To her husband he said, " I know neither you nor yoiu* wife. I do not know you." When cross-questioned he explained that he was tired of life, Ijut preferred to die on the scaffold, as that would give him time to make his peace with G-od. He had thought of insulting an ofl&cer, of killing a priest, of assassinating the president of the French Eepublic, but all these he did not wish to kill ; as he entered the theater he saw a young gii-1, but her life, too, he spared ; the married woman sitting next to him appeared to him to be the proper Adctim. [Gaz. cles tribunaux, 1851.) Was ever murder committed more deliberately? There was no doubt of his knowledge of right and wrong, but the insane motive that led to the deed would not have been suspected by any sane mind. The '' desire to hang " is not always the result of a tcedhim viUe; it comes at times in the form of an uncontrollable impulse. Such was the case of the young murderer of eighteen years who felt an ''impulse" to kill some one : he followed a boy, who was the first person he saw, to a convenient place, and murdered him in cold blood, taking e^ddent pleas- ure in the deed. He knew the boy had no ill feeling against him, "only I had made up my mind to murder somebody." He did it because he wished to be hanged, (Maudsley, p. 158.) The boy was executed, and INSA^■ITy AND CRIME. 193 the judge gave the opinion tliat he was thoronglily responsil)le, as he was al)le to understand the nature and e()nse(|nenees of liis act, and that he knew the i)unislunent was eapital. This the learned judge (considered a deeper aggravation of the erinie. But to return to melanelioly. In a state of deep depression a mother may suffoeate her child, either to end its misery or because the impulse suddenly comes upon her to change her own condition ; she feels that she must do something in obedience to an ovei-powering suggestion. Re- morse and horror follow quickl}'- upon the commission of the crime. Eveiy one can recall recent cases in which a mother has poisoned her children to keep them out of miserly, or has shot them to j^ut them out of harm's way. Melancholy patients are often under the influence of intense fear : they feel that something terrible is certain to happen, that they must act to meet the impending danger. The pent-np feelings are finally let loose, and in a state of raptus melanclwlkus a horrible crime may be committed. From a forensic point of view the question arises whether or not such persons should be permanently condemned to an asylum. That the per- son is not responsible for deeds committed goes without saying ; but this is a curable form of insanity, and for years and years not a sign of in- sanity need be exhibited. For a period of at least several years after the commission of a crime the patient should be carefully guarded and observed ; but after such a reasonable period it would seem just to give such person full liberty, but as a further safeguard the lunatic should be placed under medical surveillance for a period of at least five years, and with the first indication of a relapse should be returned to the asylum for treatment and safe-keeping. JIANIA. The term ''mania" is used to denote a form of mental disease which is the direct opposite of melancholia. The sense of the word was per- verted in the days of monomanias ; in modern psychiatry it represents the chiss of cases now to be described. In contrast to the inhibition and slowing up of all cerebral and phys- ical functions in melaiK'holy, there is in mania a decided acceleration of these functions, associated with a feeling of Avell-being. Far from lieing -depressed and without energy, the maniac is in an exalted mood, ready and able (so he thinks) to do anything : to win in any struggle, to down all enemies, and to accomplish with ease what the timid (the sane) dare not attempt. This exalted state of feelings leads to excesses and reckless- ness : he is apt to be on the go, traveling from one place to another ; goes about from club to club ; indulges himself to excess ; di'inks fre- quently; and in the full vigor of manhood worships to excess at the shrine of Venus, and boasts of his sexual performances. The psychic processes being accelerated, or, rather, all inhibition being removed, he becomes fluent of speech ; speaks on every possible occasion, sometimes sense, more often nonsense ; the association of ideas is not under restraint; he passes from one topic to another without logi- cal sequence ; like a child, mere sound is apt to suggest new lines, not of thought, but of talk, and in manv instances he begins to talk in rhyme. 194 ^ SYSTEM OF LEGAL 2IEDICIXE. He mistakes his doggerel for true poetry, and recognizes liis OTvn superior gifts. Witli the removal of that inhibitory restraint which keeps ns all Avithin bonnds, the maniac yields to every impulse, and will go to any length to satisfy his apj)etite or liis ambitions. He will seek the highest position within the gift of the peo23le, or will endeavor to establish sexual relations with women whom no one else would dare to approach (delu- sions of grandem-). If crossed in his j^lans he loses his temper, and often passes into a state of uncontrollable passion. His brain is in a constant tiu-moil ; he loses sleep and appetite, and soon becomes exhausted from physical excesses, from overinclulgence in sexual intercoui'se and in the use of tobacco and alcoholic drinks. The condition pictiu*ed above may last for years in a more or less pronounced fashion ; such patients often pass for men of unusual activ- ity and capacity until the difference between intention and actual per- formance becomes apparent. If such a condition overtakes a man who was formerly slow to arrive at conclusions, cautious and sober in his judgments, the change will be recognized by every one. At times this same patient 'will be able to give excellent motives for apparently rash acts, motives which the sane coidd not have advanced, and yet seem reasonable enough. (This special fonn is termed by the French, writers folie raisonnanfe.) The exalted mood of mania may become intensitied and will then lead to the state of frenzy, in wliich the person's will knows no restraint ; he becomes violent, destroys ever^-thing, does bodily injmy to himself, and will be liable to injiu-e any one else who crosses his path while he is in this state. The maniac comes into conflict with the law by reason of his exalted mood and the extreme mental and physical restlessness. At first he in- dulges himself in private ; as the disease increases the maniac loses the ordinary regard for public morals, will attack the opj)Osite sex on the street, will try to rape young children or to mastui'bate in public. If opposed in the execution of his plan he becomes quarrelsome and is only too quick in the use of fu'earms ; in the spirit of restlessness, and in obedience to transitory delusions or hallucinations, he ^viH. commit arson, or murder. Mania as well as melancholy often represent the initial stages of more chronic forms of mental disease, and often, too, are entirely ciu-able. The person who has been guilty of a criminal act during the period of exaltation or maniacal frenzy may ha^^e fully recovered by the time he is brought to trial. The j^hysiciau must therefore endeavor to show by a careful history of the case that the patient was actually deranged at the time he committed the act. The plea of transitory mania or tempo- rar}" insanity is often advanced in cases in which there is insufiicient rea- son for doing so. A distinction should be made between sudden extreme passion and maniacal frenzy. To prove the latter, e^ddence should be brought forward to prove derangement before the commission of the criminal act, for maniacal frenzy is never developed with great sudden- ness, and he who knows how to question and examine the accused or his relatives will be able to prove the existence of insanity before the act, if any such existed. Such cases are, on the whole, easily recognized; a. single example wiU suffice to illustrate its relation to crime : JXSJXITY AND LltlME. 105 Dr. Koster, in the Irrenfreund for 1875, relates the case of a man twent3'-nine years of Hi^a, who had an insane niothei', and who had him- self alvva3's been distin(;tly neurotic. ^Marrying a woman much older than himself, he was guyed by his neighbors, and became scnisitive to then- remarks. One evening he was aecu.scd of n(;t being the father of his chikl. This excited him intensely; he was unal)]e to win-k and be- came confused. Two days later he paced the floor until twelve o'clock iit night, and at two o'clock ran to his neighbors dressed in his night- sliirt, telling them that he had murdered his wife and child. He had choked his wife and cut the throat of the child. He spoke in a confused manner of electricity, of satirical verses pointed at him, and was e^•i- tlently subject to deliria and hallucinations of a mild order. This con- dition lasted for uearl}^ six months, when he slowly regained his mental balance. Tliis case proves how easily a person with a marked hereditary taint can pass into maniacal frenzy, goaded into the condition, as it were, by relatively slight causes. PARANOIA. The jurist's and the layman's %dew of insanity is represented best by paranoia. In this form of mental disease delusions and hallucinations play a very important part, whei-eas we have had little to say about them in the other forms previous!}' mentioned. In paranoia the delusions and hallucinations are primary symjjtoms, and not engendered on the soil of exalted or depressed emotions, as in mania and melancholia. These delusions, " fixed ideas," become systematized. They are the pivot about which the entire personality and the person's entire universe turn. They lead to the formation of an alter ego, altogether different from the original ego. The delusions dominate the mental actiWty to such an extent that they become the mainspring of all action. The paranoiac is not amen- able to ordinary reasoning, and his delusions cannot l)e dislodged l)y any power of logic. His mind is not susceptible to argument, for if it were, the delusion would of itself disappear, as the temporary delusions of the sane or of the curable insane do. He may have one set of delusions, he ma}^ have many : the persistence of one or of many proves that the entire logical apparatus is out of gear. It is absurd, therefore, to claim that a person is insane on some one point, and one point only ; he may show his insanity in one way onl}', but his mental derangement is as gi-eat as though he had dozens of fixed ideas. Paranoia is also the most tj^^ieal form of insanity, inasmuch as it shows most distinctly the effect of heredity. The fii'st signs of the in- sane neurosis can, as a rule, be traced far back into childliood. The children who ai-e exchisive, who nevei" care to play with other childi-eu, who are unusually irritaljle, who prefer to pray when others go to play — these are the very ones who develop paranoia later in life. Moody, irritable, queer, and '' cranky," they go along well enough until they have to rub up against others in the struggle for existence, or until they are overcome by some severe grief, by strong emotion, by political or relig- ious excitement (election campaigns, re\ival-meetings, and the like) ; and then delusions which may have been latent for a long time come to the foreground. On further inquir}- into the antecedent history of tlie para noiac, he will be found to come of neurotic stock, in which insanity 196 J SYSTEM OF LEGAL MEDLCLXE. liysteria, epilepsy, and clu'ouie aleoliolism have iDeen common oecmTences ^ in other cases a fall early in life, a severe infections disease, such as t^'phoid fever or pneumonia, or mastiu-bation, may appear- to have been the dii-ect exciting cause. WTiile the disease begins in early life, the full- fledged delusions do not, as a ride, appear until the age of pubert}', or possibly not untd the climacterium. The systematized delusions of paranoia may be di^4ded into tTro great groups : fii"st, delusions of persecution ; ancl secondly, delusions of grandeui'; the latter may again be subdi\-ided into religious, pohtical^ and erotic delusions. Paninoia ivifh Delusions of Fersecufion. — The patient thus affected supposes himself to be the victim of cii'cumstances, of an indi^'idual, or of a corporate body. The essence of his belief is that he is made ta suffer for wrongs which he has committed, or for en^y which others feel towai-d him. He has, as a rule, been morose, exclusive, and perhaps given to mastm-liation. He feels that he is being observed by others ; tliat the^' notice a peculiarity in him ; that they can read and conti'ol his thoughts; that the newspapers dii-ect theii' flings at him — when they speak of rascals or of thieves they mean him. Before long he hears voices ; these are the voices of his enemies, who ai"e trying to ferret out his actions ; he stops up the keyholes and di-aws the blinds of his win- dows; but his neighbors are just outside and lying in wait for him; if they cannot get rid of him as easily as they wish, they put poison in his food, which he will refuse to take from that time on. He may be the \*ictDn of socialists, of the poHce, of a definite religious sect, who will endeavor to influence him by electricity, through the telephone, through hj-pnotism, or to kill him by causing him to inhale all sorts of noxious vapors. An endless variety of delusions and of combinations of delusions and haUucinations may be the result ; but the one f eatiu'e of all is that the patient is made the victim, the sufferer. A ]3atient of mine, twenty-five years of age, who had always been morose, was suddenly seized with the fancy that an intimate fiieud of his had gained full control over his mind and prevented the free exercise of his will. One day he bought a j^istol. which he loaded and started out to find this friend and kill him ; but fortunately the fiiend was out of town. As a measiu'e of safety he was placed in an asylum, and was kept there nearly two years. In the asylum I examined the patient, found him rational in every way, and ordered his release on trial. I in- sisted on his reporting to me regidarly, which he did faithfully enough. After several months he i-emaincd away, when, to my chagTin, I discov- ered that he suspected his mother of beiug in conspiracy against him^ and that he meant to '• fix " her for it. He had to be removed to an asylum at once, where he wOl necessarily remain for a long period of time. It is easy to see that these patients are a source of great danger to the community at large ; there is no telling whom they may suppose to be the cause of all theii- misery, and against whom they may proceed ■uith murderous intent. Moved by their delusions, and regarding them as real, they act in self-defense ; for that reason they commit deeds of violence on the open highway, in public places, and in private houses : they have no fear of the result, and often glory over then' supposed victories. They discrim- INSANITY AND CHIME. 197 iiiate between individuuls, killing only tliose persons whom they snspect, while passing" others by : the law, in its great wisdom, considers this evidence of gnilt, for it proves premeditation and a knowledge of the wrong he committed. The delnsion of " m;u-ital infidelity " comes under this heading, particu- larly if it occurs in a woman, while suspicion of infidelity on the part of the wife is, as a rule, an accompaniment of chronic alcoholism in the husband. In the wife such niifontidcd suspicious are the expressions of a })aranoia persecutoria as it occurs during the climacterium. The dind- inition of sexual concourse, the waning powers of fascination, naturally suggest that the husband or wife seeks gratification elsewhere. He be- trays his relations to other women by the fact that he coughs when he passes them on the street. Tlie maid waiting at the table passes the dishes with special deference to the master of the house. An old lady of sixty accused her husl)and of nearly seventy of such illicit relations with the maid. The husl )and declared to me emphaticall}' that he desired no further intercourse with any one, and that all he cared for was to go to sleep. But the delusion persisted, and for a time quiet was restored by banishing all female help from the house except the cook, and the old lady guarded the kitchen very carefully. In other cases, again, these changes in the sexual sphere lead to the delnsion that the person has been raped in her sleep (whence false accu- sations), or that she has been led to houses of prostitution and the like ; that others are spreading such reports for the purpose of defaming her. Some feel called upon to prosecute tlie offenders in court as a matter of self-defense. Physicians play an unenviable role in some cases. A vaginal exam- ination is said to have terminated in sexual intercom-se, or possibly to have been the cause of a change in sexual feelings. Phj^sicians also play a part in mau}^ delusions of jiersecution ; above all are they frequently supposed to have gained complete mastery over the minds of the insane, and to be in a conspii'acy against them. A pa.tient of mine imagined that I had been engaged hj the family to rid them of him, and that after his death I was to come in for a share of his fortune. Paranoia with Delusions of Grandeur. — In this form Ave may classify all those cases in which the subject imagines himself called upon to fulfill some special mission. It includes the class of insane political reformers, of religious fanatics, of emperors, kings, and presidents, and those bent on soTue special mission of love. In all of these there is an exalted state of feeling such as is characteristic of delusions of grandeur. Those who find special pleasure in minute subdivisions may establish the following forms : pai-anoia ref onnatoria sen politica ; paranoia religiosa ; paranoia erotica. The political conditions of the present day are such as to arouse the dissatisfaction of nuiiiy living in monarchical countries as well as in re- publics. The sane endeavor to right such defects by the ballot and other peaceful measures. The insane, who wish to bring about great reforms, to entorce their own pet (generally foolish) schemes, are anxious to strike at once at what they suppose to be the root of the evil, and therefulism in chronic alcoholists. Morphine Habit. — Morphine is not as powerful a poison as alcohol, and, fortunately, the use of it is not as widespread as that of alcoholic stimulants. But it has fully as strong a hold upon its victims, and leads even inore rapidly than alcohol does to a degeneration of the entire nerv- ous S3'steni and to mental imbecility. The habit is engendered in many different ways. Many fall into the habit after an acute illness in which opium or morphine was given for the relief of pain. Having once tasted the sweets of the opium dream, they resort to it on the occasion of the least pain, and the very craving establishes the 2)ain. Druggists, phy- sicians, physicians' wives, and nurses fall victims most easily to this scourge, because they can easily get as much of the drug as they A\ish. The system becomes accustomed rapidly to the di*ug, and huge quantities can be taken without immediate danger to life, though many a morpliine hahifue has met his death by an accidental overdose. The condition produced by excessive use of morphine varies in differ- ent individuals. As a rule there is at first great u-ritability of temper, excessive restlessness (allayed for a time by each fresh dose), lack of energy and application to work, a distinct loss of memory, which may ultimately lead to complete apathy and imbecility. Early in the career of the morphine fiend a general depra\dty is noticeable : he shows a dis- regard for truthfubiess, and will resort to any subterfuge, even to steal- ing, to get his drug. No trick is too despical>le for the person who craves nu^rphine and cannot get it. Even in hospitals it is a common practice to bribe attendants — to make the most extravagant promises if they will secm-e the deadly poison for them ; but when the physician questions the patient he is alisolutely ignorant of any attempt at briliery. While every person may be held responsible for the beginning of the hal)it, the continuance of the habit removes such responsibility. The misdeeds of a morphine liahitue can, however, be attributed to the habit only if he exhil)it distinct symptoms of morphine insanity. He must present some siich condition as was referred to above, and a few of the ])hysical symptoms; among these the most im])ortaut are tr<'mor, ataxia, myosis, profuse sweating on the least exertion, nausea, and disgust for 208 ^ SYSTEM OF LEGAL MEDICINE. all animal food. Furuncles in tlie skin and abscesses will give some idea of the frequency of the practice. The worst crimes are not often the result of the morphine habit, but petty crimes are all the more frequent. Phj'sicians who use morphine on their own persons in large quantities become extremely careless in prescribing this and other drugs for their patients. No one who uses morphine habitually can be considered to be in a normal mental state, for his condition varies with the quantity of morphine he has in his system. As soon as the period of abstinence is reached he is possessed by a spirit of restlessness which makes him thoroughly irresponsible and incapable of sober reasoning. A common offense among morphine Jiabitnes is the forging of pre- scrij)tions calling for morphine, or the theft of morphine from the office of physicians or from the shelves of the druggist. Erlenmeyer (p. 214) reports the case of a young woman who forged the prescription of a physician calling for 1.2 niorjDh., which the patient changed to 6.2 ! adding the exclamation-mark which the German law demands in case of large doses ; the patient was sent to prison for ten days. Like alcohol, morphine leads to neglect of business, to loss of social position, and to poverty. In this condition a person who Avas once en- tirely honest will resort to petty thefts, perha,ps to help his family, but more often to secure money enough to buy morphine for himself. The general depravity of morals which the morphine habit entails is the saddest symptom of all. Not long ago I treated a once well-to-do mer- chant who had brought himself and his family to the verge of ruin by tlie use of morphine. He endeavored to free himself from the habit, but had not the moral courage to do so. In former days too proud to accept a favor of any one, he allowed his relatives now to support him and his family. The mere use of morphine is not a sufficient excuse for crime unless the distinct symptoms of morphine psychosis are present. Unless this principle is adhered to criminals might find it to their advantage to be- come addicted to the drug. In the following case this difficulty was rec- ognized, and the prisoner was declared guilty. The prisoner was twenty-nine years of age, an illegitimate child ; father unknown ; history of insanity in mother's family. With exception of syphilis the prisoner had no illness ; did satisfactory work as hospital nurse during a period of fourteen months ; in this time practiced daily hypodermic injections of morphine, began to sleep poorly, was depressed (love-affair in addition), and was not quieted by morphine. September 12, 1887, he was severely rebuked for his relations to a female nurse, and discovered that one A. liad told on him. He desired to avenge himself at once, but took morphine injection instead ; the very next morning, how- ever, he stal^bed A. while in bed and fired four bullets into his own body. Immediately after the act he appeared normal, and exhibited no absti- nence symptoms on the absolute Avithdrawal of the drug — no physical anomalies, and no stigmata of degeneration. The experts declared that morphine lial)ltues must be divided into two categories : in the one class we must place individuals with tainted ancestry and a tendency to neu- roses, who are impelled to the use of various poisons, such as morphine, alcohol, or cocaine ; the other class is made up of individuals who dis- cover the charms of morphine accidentally during a painful illness and ixsjyiTv JXD CHIME. 209 then become addicted to it. In this special ease the experts declared that the prisoner exhibited only slight symptoms of the morphine habit, that there was no trouble on withdrawing the di-ug, and that the use of morphine in his case did not in anywise affect the question of respon- sibility. He was found sane, and was condemned to five years at hard labor. (Contagne et Bernard, Arcliiv. de VAntliropoJ. Criniinelles, vol. v., No. 25.) The cocaine habit is the most recent affliction of man. It is en- gendered accidentally in the majority of cases. I have known it to re- sult from the application of the drag to the nostrils, the patient continu- ing in private what the phj'sician jiracticed upon him in his office for the purpose of treating the membranes of the nose. The sensation of apply- ing it is distinctly disagreeable, but the habit is easily developed when once begun. Those who have been addicted to morphine or alcohol, and are trying to abstain from either, often resort to cocaine as a lesser evil. And such, on the whole, it is ; but if added to the horrors of the mor- phine or alcohol habit, it makes a sad wreck of the individual. The general symptoms are very much the same as those of morpliine insanity : horrible visual and auditory hallucinations, delirium of perse- cution, visions of small animals. Intense restlessness and sleeplessness, nausea, and anorexia are the chief sjTuptoms. In one case of mine a patient who had passed with the usual success through a Keeley cure was alternately addicted to alcohol and cocaine ; he was unfitted for business, was constantly and natiu^ally at loggerheads with his family, neglected wife and children, and was a burden to his home until he con- quered l)oth habits, at least temporarily. It was my sad duty some years ago to treat a brother physician who had rid himself of the morphine habit and fell victim to cocaine, then lapsed into morphine again ; he con- tinued both drugs, was utterty unable to attend to his practice, became poverty-stricken, and finally committed suicide. The drug does not fascinate the indi^-idual as morphine does, nor has it, to the writer's knowledge, led to any serious crime as yet, except that of neglecting one's family and of leading to suicide ; but let it be con- tinued, and the danger of criminal acts on the part of the cocaine habitue becomes probable enough. HYSTERICAL EsSAXITY. In my lectures to physicians on nervous diseases, I am in the habit of saj'iug that hysteria in this country is a rare form of disease. Startling as this statement may seem, it is absolutely true if we restrict the term to the graver form of the disease, and do not make the diagnosis of hysteria for the same conditions to which, if they occur in man, we apply the term " nervous." Hysteria leading to crime is still rarer in this country, but is becoming more and more frequent among the Russian, French, and Italian elements of our mixed popidation. The aggravated forms of hysteria are most common in France, and have been studied most carefully by French medical writers, alcove all by Charcot and his fol- lowers. They have created the modern concei)tion of hysteria. Hysteria proper, la (ivaudc hijsterie, the condition M-ith which we are most concerned in this article, is characterized hx an unusual develop- ment of the emotional faculties. The slightest cause is sufficient to 210 J- SYSTEM OF LEGAL 2IEDLC1XE. produce great emotional distm*bauee ; tliere is a continuous alternation between pleasurable and depressed moods, the latter preponderating. Hj^oehondriacal tendencies are common. • Every sensation, however slight, is tiu'ned to account ; danger and ill health are always impending. By close observation of their o'^vn physical condition, patients become egotistical and selfish to an unusual degree. Every one is made to dance attendance U23on them, and from theii' own selfish point of \ievr they are the pivot about which everything tiums. They are ever mindful of themselves and culpably indifferent toward others. If the family grow^ callous toward their sufferings, they exaggerate these, and will simulate all sorts of conditions ; wiU run any and every risk (tui'U on the gas,. swallow glass, needles), will do anything to attract attention ; wiU de- liberately commit suicide for the sake of a moment's notoriety, in which they are often aided by oui* sensational press. If they fail in such efforts, hysterical indi^s-iduals (men as well as women) become revengeful, and if the excitement increases (in women at the time of menstruation more particularly), deliria and delusions of persecution may be developed. The sexual sphere is frequently involved, and under the influence of erotic delusions respectable Avomen may prostitute themselves or imag- ine themselves the \dctims of man's sexual passion. False accusations and denunciations are the accompaniment of this condition. Mysterious cases of rape that have baffled the police have been explained as the re- sult of erotic delusions on an hysterical basis. In the condition of ex- haustion associated with severe hysteria, morbid impulses arise wliich may lead to offenses against the law. Hysterical women, in their ego- tism, learn to despise their offspring ; one such mother told me that she- hated her child, and could kill it for the pain it gave her during labor. The responsibihty of an hysterical indiAddual will have to be deter- miined in each individual case ; to say that a j)erson is hysterical is surely no sufficient excuse for crime. In every case the e^ddence of severe hys- teria should be requii'ed. This can be accepted only if the person has been subject to severe hysterical manifestations for a long period of time. Chief among these are : unusually A^olent and sudden changes of moods ; hysterical fits and hysterical trance conditions i^rovoked by pressure upon hysterogenic zoiies. And in addition there are a few physical signs of importance : marked vasomotor distui'bances, anaesthesia of one half of the body, with distinct involvement of all the special senses in that half, or patches of anaesthesia ii'regularly distributed over a large portion of the body. These objective SAmiptoms will prove to be of great value in a given case. They will help us to differentiate between a mere " hys- terical " indi\ddual and one suffering from hysteria major. Hysteria of a grave order, hereditary hysteria in particular, is the mark of a general psychic degeneration, and as such is often associated with more serious mental disturbance. The following examples will suffice to illustrate the forensic importance of hysterical insanity : An unmarried woman thii'ty-eight years of age accused her father that he allowed another person to enter a room occupied by herseK and sister, and that this person raped both of them ; " for two years she has^ been pregnant by this man." She was not allowed to bring suit, so she armed herself and meant to waylay the offender. She was sent to an asylum, where she improved. On her disuiissal she met a lawA'er, who thought her sane and began suit against the father and the dii'ector of IXSJXITV AND CHIME. 211 the asj'luni for illegal detentiou ; but her insanity was recognized. (See also Morel, p. 087.) From Iluinmoiid I take the following case: "In 1873, says M. Hu- -chard, Mile, de JM., aged eighteen years, accused the vicar of the parish of liaving committed a rape upon her. She stated that on such a day and at such an hour, while she was saying her prayers in church, the vicar, after having shut all the doors, approached her and requested her to go with him into the sacristy. There he had made, she declared, indecent proposals to lier, and, as she repelled him with indignation, he had pointed a dagger at her heart. She hnd fainted, and when she recovered her senses she discovered that she had ])een violated. During the trial of the accused priest the medical experts questioned her in regard to the moihis f((cie)idi, and as she answered by giving childish details, she was submitted to physical examination, with the result of ascertaining that she was a virgin, and that there were no traces of violence." " Tardieu refers to a recent case, that of a young girl, an inmate of a convent in Gascony, wlio persuaded her father that she had been made the victim of all kinds of tortures and unheard-of outrages. He, believ- ing what she said, went before the authorities and denounced the alleged perpetrators. Finding, however, that she had deceived him, not a word •of her story being true, he took his hfe from chagrin and mortification." To the above might be added another case, also cited by Hammond, in wliieh the termination was sad enough : '• The Marquise de Prie, mistress of the Duke de Bom-bon, was exiled from court, and, of course, indifference and neglect followed her in her retreat. She, however, resolved to regain, by a coup de theatre^ the favor she had lost. She announced that on a certain da}' of the month, and at a certain hour, she would kUl herself. Ev'ery one was amazed at the declaration that one so j'onng, beautiful, and attached to life contem- plated suicide, and the news was received with derision. During the few days intervening, the marquise gave several fetes, at which she danced, played, and amused herself as in the days of her highest favor. No one had ever seen her gayer, more spirited, more adorable. The hour arrived. She called the new lover she had chosen to her side, and again announced her detei'mination. The communication was received by him with a smile of incredulity. Believing it to be one of those mystifications to which she was accustomed, and that she was acting a part, he himiored her so far as to give her, with his own hand, the draft she had pre- pared. It was in reality poison, and she died before assistance could be given." NEURASTHENIA. Neurasthenia is so common a disorder among men and women of oiu* busy world that it has become a well-recognized form of disorder even among the laity, under the terms of nervous exhaustion, nervous prostra- tion, and the like. It would have little forensic importance were it not for the fact that it is frequently the first sign of an inherited taint, and that it represents at times the first stages of more serious mental disturb- ances, such as hypochondriasis, paranoia, and even dementia. In neuras- thenia, moreover, there are periods of excitehient in which the individual is not fully responsible, and, above all, morbid conceptions and morbid 212 ^ systi:m of legal medicine. impulses are frequent. These have been fully described in the intro- ductory pages of this article. In former days, and in mam' countries to this day, the law did not recognize such conditions. In the majority of instances the individual is able to resist such impulses, but every now and then criminal acts i-esnlt directly from such impulses, or the contin- uance of such morbid fears and impulses leads to a coofusioual condi- tion in which the sufferer becomes wholly irresponsible. Special cases need not be cited, as the commission of crime is, after all, rather rare, and neurasthenia should be accepted as an excuse for crime only if de- cided mental changes can be proved to have existed. HYPNOTISM. The discussions of hypnotism in the secular press are in inverse pro- portion to the importance attached to it by medical men the woi-ld over. Even in France, where the schools of Charcot in Paris and of Bernheim in Nancy have done so much to popularize the subject, the medical men as a bod}^ have not failed to recognize the limitations of the subject. For the present hypnotism is of greater theoretical than practical importance both from a medical and a forensic point of view. Charcot, Richer, and their followers regai'd hypnotism as a condition similar to grand hysteria^ whereas the followers of Bernheim hold that it is a condition produced by mere suggestion, and that this condition can be excited in non-hys- terical as well as in hysterical suljjeets. The present Avriter believes that all " impressionable " individuals can be hypnotized. The novelists have made much of these phenomena of hypnotism, both from an intrinsic psychologic interest, and because it makes theii* task very much easier. It is fascinating, I am certain, to be able to change the characteristics of one's hero at will, to subject him to all sorts of occult influences, without being called upon in the good old-fash- ioned way to explain minutely how such changes were brought about. "Hypnotic influence" is a convenient subterfuge. In novels this influ- ence is generally exercised for evil, although Du Maurier, in the influence which Svengali exercises over Trilby, makes an exception to this ride. The lay public has feared that under the influence of suggestion an evil-minded person might suggest to another the commission of a crime, and that the hypnotized subject, deprived of his free will, •would forth- with proceed to obey the suggestion. In medical circles sham murders (with wooden daggers) have been committed in obedience to su(!h a sug- gestion. The possibility of actual murder being committed cannot be denied. The practice should, therefore, be limited by law, and public exhil)itions should be entirely prohibited. But, fortunately, no serious crime has as yet been committed, to my knowledge, in obedience to an hypnotic suggestion, and the efforts to prove hypnotic influences in recent French trials have failed utterly. There is eA'er}^ probability, too, that the instigator to such a crime could be easily detected if the subject were rehypnotized by a competent person or commission ap- pointed for this purpose. In the hypnotic state information or hints Avould be given which would lead to the discovery ; in the interval be- tween such states the subject would be ignorant of everything that had occurred. The suggestions nuide with e^dl intent dming the waking iy.'s.L\iTy AM) cniMi:. 21 ;i state arc still of far greater importance than those issued to a liypno- tizecl iiuUvidual. Before ('oiicludiiig this artic'le, the writer wishes to impress upon the medical man and the jurist the following considerations: In determining the (question of responsibility of an individual, the older tests of knowledge of right and wrong, of free will, of premedita- tion, should be disregarded altogether. The only duty the medical expert has is to state and to prove whether the accused was or was not insane when the act was committed. To strengthen such evidence he should be able to state the symptoms pointing to a special form of insan- ity, as he would l)e expected to state them in a case of pneumonia or any other purely i)hysical disease. Insanity should be a sufficient excuse for crime, whether or not a sane mind can fathom the relation l)etween the insane condition and the criminal act. Crime committed liy persons addicted to alcohol, morphine, cocaine, or any other poisonous drug can be excused only if such addiction has led to the development of a distinct form of insanity, EXAMINATION OF INSANE CRIMINALS. A word only with reference to the proper method of examining in- sane criminals. The method employed shoidd be very much the same as with other insane patients, bearing in mind that among the crinnnal classes, or those accused of crime, simidation is very much more fre- quent. But as simulation is discussed by another author I may disre- gard it altogether. In examining a patient or criminal, take note first of his surroundings, of his apjiearance, of his behavior before you enter, and while you are with him. Note whether he behaves under ex- amination as any otlier insane person would, and, al)ove all, a person with the same form of insanit3^ If the examiner has had considerable experience in insanity it wiU be possible for him to speak very definitely on this point. A few years ago the writer was asked to see a prisoner who had en- tered the plea of insanity for his ndsdeeds in the commercial world. He pretended to be suffering from delusions of persecution, and refused to take the prison food, lie insisted on cooking his own food, but took very freely some nu'dicine (an hypnotic) prescribed by the prison physi- cian — the very last thing an insane individual would have done. Instead of referring to his persecutions, or of explaining win' he should be perse- cuted, he kept on saying that his head ached ; that " if he could get down to Wall Street he would make it all right again." The man who spoke so freely under exannnation in private maintained absolnte silence and indifference in court. The discrepancy between his behavior and that of tlie truly insane with such delusions was so different that there was little doubt of simulation. It is best to enter upon the delusions of the insane, and to converse freely with them, as though the examiner were convinced of the truth of the premises. Avoid leading questions, but try to follow along the line of argument adopted by the insane, and in this way the faidty rea- 214 -i systjlM of legal medicixe. souiug and faulty judgment will be easily detected. It requii-es great patience on the part of tlie examiner, more especially in those eases in which the person examined refuses to talk. As with the non-criminal in- sane, the conversation has to be begun again and again, or repeated visits made, before a successful result is reached. In some cases it may be necessary for the physician to disguise his own person, or to appear under some assumed name and in an assumed function, but the dignity of the profession requires that this should be avoided whenever possible. Often, indeed, the very conduct of a person knomng himself under examination gives the best clew to the actual mental condition. The crime of which the person is accused should form the chief but not the sole topic of conversation, and the examiner must endeavor to get at the motives which inspii-ed the criminal act; also whether the accused feels any remorse, whether he would have the deed undone. And after this topic has been exhausted a general examination should be made with the view of determining the person's mental capacit}-, his knowledge of other events, his memory, and his moral as weU as rehgious views. The physical exa,mination is equally important : the formation of the skull, his physiognomy, the action of the pupils, the x^resence or absence of tremor, his speech, his wi-iting, his gait, Ms heart, his general physical condition — all these points should be carefully noted, and will help to form a definite opinion of the individual's mental status. But the sint qua non of a successful examination is that the examiner should know what to look for, and that he should have had previous experieuce ^vith the non-criminal insane. BIBLIOaRAPHY.* Allison, "Am. Journal of Insanity," Jxily, 1894. Baer, "Der Verbveeher in anthropologiseber Bezieliung." Leipzig, 1S93. BenediJct, " Kraniometrie u. Keplialometrie." Lectures. Vienna, 1888. Benedikt, article on " Cranial Measurements " in " Eulenburg's Enevklopadie." JBucknill and Tul-e, " Manual of Psychological Medicine." Casper-Liman, "Handbueli der gericbt. Med.," 7tb ed. Charcot, " Maladies du Systeme Nerveux : Iconographie Salpetriere." Progres medical of the last ten years — chiefly for hysteria and h^iDnotism. Clarle, "Heredity and Crime in Epileptic Criminal Brain," 1880. Contagne ct Bernard, "Arch, de I'Anthropol. Crira.," vol. v., Xo. 25. CrotJiers, various articles in the "Journal of Inebriety," edited by him. Despine, "Psychologie Naturelle." Paris, 1868-70. 3 vols. Dufonr, " Virchow's Jahresschr," 1888, vol. i., p. 64. Ellis, "The Criminal," "Contemporary Science Series." Erlenniei/er, " Morpliimnsueht" (Morphine Habit"). Monograph. 3d ed. Berlin, 1887. Esquiroi, "Malad. Mentales," 1838. Still worth consulting. Griesinger, "Pathologie u. Therapie der Psychisehenkrank.," 2d ed., 1861; Sydenham ed", 1867. Hack-Tiike. London, 1891. * This is not intended to be a complete list, but to include such works as have been considted in the preparation of this article, and those which the alienist or the jurist would do well to consult in further studies on this subject. BiBLWunAriJY. 215 Hammond, "Treatise on Insanity," 1883. Hirsch, " Genie uud Eutuitung." Berlin and Leipzig, 1894. Contains critical studies in opposition to Lonibroso's theories. Huchanl, " Caraetei-e, Moeurs, etc., du Hysteriques." "Arch. d'Xeurologie," March and April, 1882. Jollji, article on "H\'steria" in " 2ienissen'.s Cyclopaedia." Kane, "Alienist and Neurologist," Jnly, 1882. lufchhoj)', " Lehrb. d'Psych.," 1892. Am. ed. by Wood & Co. Contains excellent piiotograpliie reproductions of insane faces. Koshr, "Irreiifreund," 1875. Krat/t-Ehiiu/, " Gericlitliche Psyehopathologie," 3d ed., 1892. A very full treatise, with ample references. See also communications in " Friederich's Blatter," 1872 and later years. Eurella, " Naturgeschiehte des Verbrechers." Stuttgart, 1893. Lawson, " Insanity as a Defense to Crime." St. Louis, 1884. An excellent legal summarj\ Legrand du SaulJe, "La Folic." Legrand da Saidle, " Etude Med. -Leg. sur I'Hysterie et sur le Degr6 de EesponsabUit^," etc. "Gaz. des Hop.," 1859. Lloj/d, "Journal of Nervous and Mejital Dis.," 188G. Lombroso, " L'Uomo Delinquenti in Eapporto all, Antropologia Giurisprudenza," etc., 3d ed., 1884. German translation by Fraenkel. Hamburg, 1887. Lombroso, " Neue Fortsehritte," etc. German transl. Leipzig, 1894. Lowenfeld, "Neurasthenie u. Hysterie." Wiesbaden, 1894. Maudsley, "Responsibility in Mental Diseases," 4th ed. D. Appleton & Co., 1881. Mendel, "Dementia Paralytica." Berlin, 1880. Also article on "Moral Insanity," "Eulenburg's Encyklop.," 1888. Meyer, L., "Die Stellung der Geisteskrank., etc.," zur Kriminalgesetzgebung." "Arch. f. Psych, u. Nervenk.," 1870, vol. ii. JlfeyHe>-f, "Gehirn u. Gesittuug." Vienna, 1889. Lectui'e. Also " Psvchiatiy " (transl. by Sachs), 1885. Moeli, " Ueber irre Verbrecher," 1888. Morel, "Traite des Malad. Ment.," 1860. mcolson,/' The Morbid Psychology of Criminals." "J. of Ment. Sc," 1874, vol. xx. Prichard, " Treatise on Insanity," 1835. With especial reference to moral in- sanity. liaii, " Treatise on the Medical Jurisprudence of Insanity," 1860, 4th ed. liohlnson, W. R., "Journal of Nervous and Mental Dis.," May, 1887. Hush, B., 5th ed., 1835. Sachs, B., "What the Law can Do to Mitigate the Evils of Medical-Expert Testi- mony." "N. Y. Med. Examiner," July, 1892. JSauder and Eicliter. "Geistesstorung u. Verbrechen." Berlin, 1886. Schiile, "Psychiatrie," 1878. Smith, A., "On the Position of the Medical Fraternity with Reference to the Abuse of Alcohol." "Berl. Klin. Wochenschr.," 1894, No. 31. Sommer, "Beitrage zur Kenntniss der kriminellen In-en." "Allg. Zeitsehr. f. Psych.," 1884, pp. 88 et seq. Sommer, "Ueber Trunksucht." Konigsberg, 1888. £pif~ka, "Insanity: Its Classification," etc., 1883. JStriimjycll, "Die Alkoholfrage vom aerztlichen Standpimkte." "Berliner Kl. Wocli- enschrift," 1893, No. 39. Taguet, "Du Suicide dans I'Hysterie." '-'Annales M^d.-Psyehologiques," May, 1877. Tardieu, "Etude Med. -Legale sur la Folic." Paris, 1892. Tliompson, "Journal of Ment. Science," January, 1870. Thompson, "Psychology of Criminals." "J. of Ment. Sc," vol. xvi. Westphal, "Arch. f. Psychiatrie," vol. iii. and vol. ■yii. Wharton and Stille's "Med. Jimsprudence," 3d ed., 1873, vol. i. ON THE RELATIONS OF MENTAL DEFECT AND DIS- EASE TO CEIMINAL RESPONSIBILITY. By LOUIS E. BINSSE. THE THEORY OF CRIMINAL RESPONSIBILITY. The criminal law of Eugiaud recognized at an early day the existence of mental defect and disturbance, and in a rude and nnscientific way attempted, according to the methods of the medical science of the time, a classification of its varieties and degrees. Coke, in the Commentary on Littleton (Co. Lit. 246&, 247a) and in Beverley's Case (4 Co. Rep. 123&), makes the following distinctions: " Here Littleton explaineth a man of no sound memorie to be non com- 2)os mentis. Many times (as it here appeareth) the Latin word explain- eth the true sense, and calleth him not atnens, dentens, ft(riosus, houificus, fatims, stidtns, or the like, for iton compos mentis is most sm-e and legall. Non compos mentis is of four sorts : 1. Ideota, which from his nativitie, by a perpetnall infirmitie, is no)i compos mentis. [Idiot or fool natural.] 2. Hee that by sicknesse, griefe, or other accident, whoUy loseth his memorie and understanding. [He who was of good and sound memory, and by the visitation of God has lost it.] 3. A lunatic that hath some- time his understanding and sometime not, aliquando gandet Jucidis inter- valliSj and therefore he is called non compos mentis so long as he hath not understanding. [Luncdicus, qui gandet lucidis intervdlJis, and some- times is of good and sound memory, and sometimes non compos mentis.] 4. Lastly, hee that by Ids owne vitious act for a time depriveth himselfe of his memorie and understanding, as he that is drunken." [By his own act, as a drunkard.] At a later day, Sir Matthew Hale (Hale, P. C, chap, iv.) made a simi- lar but more detailed classification. Mental defect and disease he called dementia, the state of being out of one's mind. This he divided into three great classes : I. Natural dementia, that is, idiocy, or fatuity from birth. II. Accidental dementia or insanity. III. Voluntary dementia or drunkenness. In the second of these classes, that of insanity, he distinguished total from partial insanity ; the latter being partial in respect to its subjects, or partial in respect to its degrees. He further took note that it was, as to its nature, at one time permanent, at another time occasional. Tlie former he called phrenesis or madness, the latter lunacy, from tlie con- temporaneous error that mental disease was influenced by the phases of 217 218 ^ SYSTEM OF LEGAL MEDICINE. the moon. In addition to the ijiere loss of the use or exercise of reason, he recognized tlie furtlier condition of a superadded state of violence or fury. This he called furor, rabies, or mania. However unacceptable these classifications may be to advanced medi- cal science (Prichard On the Different Forms of Insanity, London, 1842, p. 9), the}^ form the necessary basis of anj^ consideration of the subject from the legal point of view, for, up to the time of the answers given by the judges of England to the questions put them by the House of Lords in consequence of the acquittal of Daniel McNaghten (10 CI. & Fin. 200), the writings of Coke and Hale, together with the instructions given by judges in particular cases, constituted the exclusive authorities on this subject. Although the law, speaking thus through its sages, has attempted to classify according to the methods of medical science mental defect and disturbance in its varieties and degrees, it contemplates them from an altogether differing standpoint. Medical science deals with the causes of mental disease and seeks knowledge on the subject for a piirely medi- cal end. With it an inquir^^ as to the fact of insanity is an absolute and final one. The law, on the other hand, neglects the causes of insanity and deals exclusively with its consequences, which are evidenced by con- duct, the outward expression of the inner mental state. From this point of view there are two forms of insanity — the one that causes a man to break the law, the other that does not cause him to do so. The fact of insanity is not therefore in the mind of the law the ultimate end of its investigation, but one relative to the broader inquiry as to the fact of responsibility or punishabilitj^ Even in respect to this the two sciences have different starting-points : the one, beginning with the fact of dis- ease, seeks to measure its disturbing influence qu the conduct of particu- lar members of the community governed by a code of moral and social obligation ; the other, at the opposite end, sets out from the standpoint of moral and social requirements and assumes that all men are sane, and consequently responsible for their acts until in individual cases they are proved not to be so. (Minshall, J., State vs. Bowslier, 3 Cin. Law Bui. 187 ; Curtis, J., U. S. vs. McGlue, 1 Curtis, 1 ; " Responsibility in Criminal Cases," by David Nicholson, M.D., Jonr. of Mental Sci., vol. xxiv., p. 1 ; " On the Relation of Madness to Crime," by J. C. BuckniU, M.D., Am. Jour, of Insanity, vol. xl., p. 412.) In a criminal trial, when mental defect or disease is pleaded as a defense, the question is " whether the accused be guilty or not guilty." (Mr. Justice Maule, McNaghten's Case, supra.) In this fact of guilt is involved the fact of the evil mind, for although the criminal law takes cognizance only of the exterior act (Montesquieu, Esprit des Lois, chap. xi.),* and not of the mere interior intention, yet it is a fundamental maxim that " the act itself does not make a man guilty, unless his inten- tion were so." (3 Inst. 107.)t A criminal act is therefore complete only when the evil mind concurs with the outward act ; and in the iiu|uiry as to the existence of this evil mind, the fact of mental defect or disturbance is pertinent, as a traverse of the evil mind's essential constituents, of will, intention, or malice. * "Les lots ne se chargent de punir que les actions exterienres." t "Actus nonfacit reum nisi mens sit rea." MENTAL RESPONSIBILITY IN CHIMIN J L CASES. 210 (Stei)lieii'.s General View of the Cnmimd Laiv of Eiif/Jiiii(l, chap, iii., p. 8G.) lu notliin^ more than this has the law appreciated the futility and peiil of definition, the impossibility of defining or describing the disease or of hiving down any test of its existence. (Lord Lyndliiu'st^ Hansard's Debates, vol. Lxvii., third series, p. 716 ; Lord Denman, lie(/ina vs. Oj-fonl, 9 C. & P. 525.) It has therefore refrained from making a special issue of the fact of insanity and has limited itself to the estab- lisinnent of a canon of responsi])ility, legal insanit}^ being commensu- rate with legal irresponsil)ility. " Our law was," says Erie, C. J., " that a man was responsible for liis acts unless his mind Avas in a state which prevented Mm from being responsible for his acts. If he was conscious that he was doing wrong at the time when he committed the act then he was responsible. . . . The question was whether he was or was- not responsil)le when he committed the act — not whether he was not guilty on the ground of insanity : that was an issue far too vague, indefi- nite, and undefined. The issue was, whether or not when he did the act he was legally responsilile — in other words, whether he knew its nature, and knew that it was ^vi'ong." {Eegina vs. Leigh, -4 F. &: F. 915,) The distinction thus made between insanity and responsibility marks thfr boundaries of the separate and distinct pro\dnces of law and medicine. Tlie ditfereuce between mental health and disease is, and must remain, a fact of science entirely within the purAnew of medicine. On the other hand, the determination of the relation of mental disease to guilt, and to the punishaliility of such guilt, and of the point of separation between the conditions of responsibility and ii-responsibility, must be the exclusive function of the law. '-The question," says Sir J. F, J. Stephen, "AMiat are the mental elements of responsibility ? is, and must be, a legal ques- tion. It cannot be anything else, for the meaning of responsibility is liability to punishment, and if criminal law does not determine who are to be punished under given circumstances it determines nothing." (Stephen's Hisfori/ of the Criminal Law of England, chap, xix., p. 183.) From the natm-e of things, the law must determine for itself, and in the first place, whether or not the fact of insanity should exempt one at all from the ordinary hability of the criminal law, and, ha\dng admitted the exemption, it must set and define the limits of such exemption. For in- stance, as a rule of policy, the law might determine that no degree of madness should exempt, or that any degi-ee of madness should so ex- empt ; or it might place the point of responsibility, as it does, somewhere- between these two extremes. The Supreme Court of New Hampshii'e {State vs. Jones, 50 N. H. 369), which has gone to the extreme in its rejec- tion of the legal criterions of responsibility by leaving to the jury, as matters of fact, whether the accused had a mental disease, and whether the overt act was a product of such disease, impliedly laid down the cri- terion of legal responsibility that no man should be held accountable criminally for an act the offspring or product of mental disease. Ac- cording to the G-erman jurist Casper the term criminal responsibility is easily defined, since it is based upon unchangeable natural psychological laws, recognized by every man's conscience, and which may be compre- hended in the following simple dogmas : 1. Both a good and exil prin- ciple reside and act in man. The recognition of this fact is coeval Avitli the origin of man, and is expressed in the most ancient religions. 2. This double principle itself, as well as the power of recognizing it, is born with. 220 ^ SYSTEM OF LEGAL MEDICINE. eveiy man, and is firmly based in liis conscience so long as he remains in Ills natiu-al condition. 3. Man in liis normal condition is at perfect liberty to permit Mmself to be gnided in his actions by either the good or the bad principle ; " he has freedom of choice," according to others, " the power of spontaneous action," " moral fi'eedom," or " the freedom of the will." 4. Every man knows, and so long as he continues in his normal condition must be presupposed to know, that, in s]3ite of his free- dom of choice, he must allow himself to be guided in his actions by his good principle, and withstand the allurements of his evil one. 5. And that when he acts reversely he exposes himself to the punishment of his internal .judge, his conscience, which dwells "s^dthin him as the natural guardian of the laws of morality. These are eternal, inborn truths, the foundation-stones of the whole doctrine of criminal responsibility, to which the following may be added, if, indeed, they do not actually belong to the same category : eveiy man li^dng in the bonds of society, who has aiTived at the normal development of his mental powers, has experi- enced and knows that society is not and cannot be satisfied by the pun- ishment inthcted by his internal monitor, but, in accordance with the re- quii'ements of the inborn laws of morality, has also laid down and put in execution external punishments for any action opposed to morahty. In accordance with these laws, therefore, he must be made responsible for every rash deed so long as he is in the unclouded possession of his men- tal powers, since, in such cii'cumstances, he is in a position to foresee all, even the e\-il results of his actions ; he is possessed of criminal responsi- bility. {HandhooTx of the Practice of Forensic Medicine, vol. v., part vi., chap, i., sec. 58.) The law of England, in the same manner, places the foundation-stones of criminal responsibility in the intuitions of conscience and the enact- ments of positive law, in relation to which it recognizes in the normal man a liberty of mil, a capacity to follow the one or obey the other. Inasmuch as there can be no liberty of will Avhere there is no under- standing (Hale, P. C, chap, ii.), it has assumed the truth of the correlative proposition that where there is an understanding sufficient to know the thing chosen, good and evil, the freedom of the will exists to the extent of conferring responsibility. It has placed, therefore, the capacity to form the evil intent exclusively in the consciousness or understanding of the individual, making it thus the touchstone of responsibility ; a cri- terion which it applies to the "natm-al defect" of infancy (Hale, P. C, chap, iii.) as well as to the "accidental defects" of idiocy and insanity — to those who are nan compos mentis. " On the part of the defense, it is contended," says Lord Denman, "that the prisoner at the bar was non compos mentis, that is (as it has been said), unable to distinguish right from ■s^^:'ong," or, in other words, " that from the effect of a diseased mind he did not know at the time that the act he did was wrong." {Eegina vs. Oxford, 9 C. & P. 525.) I. NATURAL DEMENTIA OR IDIOCY. Although Hale elaborately distinguishes idiocy from insanity, there would seem to be no sufficient legal reason for this distinction, as the consequences of the knowledge of the nature of an act do not vary with causes purely physiological in their difference, such as the difference in- MENTAL BESrON.^lBlLITY IN ClilMINAL CASES. 221 •trmsically motlical made between mental weakness and disease, and the Such jjersons as have their lucid int(irvals (which ordinarily happens between the full and change of the moon) in such intervals have usually at least a competent use of reason, and crimes committed b}^ them in these intervals are of the same nature, and subject to the same punishment, as if they had no such deficiency." (Hale, P. C, chap, iv., p. 31.) That the occurrence of the lucid interval constituted in the mind of the law a restoration to reason, or to the competent use of it — in otliei' words, a tem])orary cure — seems plain from the authorities. Lord Thurlow {Affo)-iiPi/-General vs. Farnther, 3 Bro. Ch. 441) defined a perfect interval not to be a cooler moment, an abatement of pain or violen(;e, or of a higher state of torture, a mind relieved from excessive pressure, but an interval in which the mind, having thrown otf the dis- ease, has recovered its general habit. And Baron Rolfe, in liegina vs. Latjtou (4 Cox, C. C. 149), instructed the jury 'Hhat such was the natiu'e of the mind that it might be one minute sane and the next insane." If such were the real and essential character of a lucid interval, there could be no just criticism of the criterion of responsibility based upon its occur- rence; but the current legal view as to its intrinsic nature has been vehemently disputed by mental phj^sicians, some of whom deny alto- gether its existence, and others regard it as being only a remission, not an intermission, of the disease — an abatement of the severity of the symp- toms, not a temporary cure. (Ray's Jurisprudence of lusanifi/, chap, xv.) The question, however, has only a s^^eculative interest in forensic medi- cine. In the year 1816, at a Court of General Sessions held in the city of New York, one Clark was convicted of petty larceny alleged to have been committed during a lucid interval (1 C. H. Rec. 176). This case, however, cannot be considered a precedent, and it is authoritatively asserted that the books contain no other record of a similar cou\'iction. (Ray's Jurisprudence of Iiisanifi/, chajD. xv., p. 427.) Casper testifies to a like experience on the continent of Europe : " Experience teaches us in regard to the whole question of a lucid interval, what I have never seen stated, that practically speaking it is in so far of little importance that it is but S(ddom mentioned in foro. At least, of hundreds of erinunal cases which I have reported on, I have never had to do wdtli one in which the question of a lucid interval came in question at all." {HandbooJc of Fo- rensic Medicine, vol. iv., part vi., chap, ii., sec. 78.) Epilepsy. — The occurrence of the epileptic paroxysm, which, con- sidered as an interval, is the I'cverse of the one we have been consider- ing, cannot be inferred from the fact that the accused Avas suffering from epilepsy, a disease which has a tendency to weaken the mind and to ])r()- duce insanity. In addition, proof must be given of the occurrence of the paroxysm at the very time of the commission of the deed. {Conunon- icealfh vs^Bu^cieri, 153 Pa. St. 535.) 224 ^ SYSTEM OF LEGAL MEDICINE. (b) Partial Insanity. — It lias been contended, npon the theory of the essential nnity and indivisibility of the lininan mind, that there is in fact no insanity which can with substantial accuracy be described as a partial one. ( Waring ys. Waring, 6 Moore, P. C. 341.) In the criminal law, however, there can be no donbt as to the authority of the distinc- tion made by Hale between the conditions of total and partial insan- ity. The latter condition, wherein persons who labor under mental dis- ease with respect to one or more objects, are entirety, or apparently entirely, rational with respect to others (Lord Lyndhurst, Hansard's De- bates, vol. Ixvii., third series, p. 712), forms the almost exclusive subject of inquiry and the exclusive difficulty when insanity is interposed as a defense in courts of law. Until the acquittal of James Hadfleld (suj^ra), a condition of partial insanity was, to the accused, no exoneration. ^' This," says Hale (P. C, vol. i., p. 30), " is the condition of very many, especially melancholy persons, who for the most part discover this defect in excessive fears and griefs, and yet are not wholly destitute of the use of reason; and this partial insanity seems not to excuse them in the committing of any offense for its mt^tter capital ; for doubtless most per- sons that are felons of themselves a.nd others are under a degree of partial insanity when they commit thee: offenses." In the earliest cases the insanity that might acquit must extend to the total deprivation of ''understanding and memory," so that the accused might "not know what he was doing no more than an infant, than a brute or a wild beast." (Trial of Edward Arnold, supra.) This, derisively called the "wild-beast theory," had for its basis the fact of the comparative indestructibilitj^ of the capacity to know good from evil; which, not being a process of thought, nor taking its origin in the intelligence, but much deeper in the mind, in the consciousness itself, insanity in its highest degree alone can ■obliterate. (Casper's Handhooh of Forensic Medicine, vol. iv., part vi., chap, i., sec. 63). "A child," argued the attorney- general in the case of Hadfield (supra), " cannot dispose of his property in any manner what- ever, and no man would think he had a capacit}^ for that purpose ; but he has sufficient capacity to be guilty of a crime. Why i Because there is a natural impression upon the mind of man of the distinction between good and evil, which never entirely loses hold of the mind while the mind has any capacity whatever to exert itself ; nothing but total and absolute debility deprives the mind of any man of that." And with this the inductions of mental medicine are agreed : " The sense of duty, the feeling of right and wrong, is an innate principle of the human mind implanted by the Almighty and serving as a sure foundation for the re- sponsibility of man for his actions ; which is thus not left to chance de- velopment, but is rendered an essential and neciessary part of human nature. It seems needful to inquire to what extent this abstract and necessary part of human nature becomes capable of being perverted or destroj^ed under the influence of cerebro-mental disease. It may be taken as an axiom that the innate and essential princqjles of mind are ever present tvliere mind exists. It may also be asserted, as the result of obser- vation and experience, that in all lunatics, and even in the most degraded idiots, whenever manifestations of any mental action can be adduced, the feeling of right and wrong may be proved to exist." (Bucknill on Crimi- ^lal Lunacy, p. 59.) The fact of the comparative indestructibility of the capacity of know- MENTAL RESPONSIBILITY IN CRIMINAL CASES. 225 ing good from evil furnishes, as will he shown, the essential i-eason for the objeetious advanced against it as the exclusive criterion of legal re- sponsibility. From this standpoint, too, does the law consider mental defect and disease in the comparative relations of " civil competency " and " criminal responsibility." An infant, a man incompetent for ci\il affairs or the "constant duties of life/' ma\', notwithstanding, he crind- nally responsible. ( Att(n-ney-Ueneral, Trial of Hadlleld, supra.) Thomas Bowler, found guilty in the year 1812 of willfiUly and nirdiciously dis- ■charging a l)lunderbuss loaded with l>ullets at one Burrows, was after- ward executed, altlu)ugh previous to the comndssion of the deed he had been adjudicated incompetent for the management of his affairs under an inquisition in lunacy. (1 Coll. Lun. 673.) A hke doctrine, founded upon similar reasons, is set forth by the Continental juiists: "The fact that the conditions of criminal responsibility are inborn in man and are <;onsequently deeply rooted in the whole of his psychical organization, while other psj'chical processes are the result of education, of mental cultivation, of indoctrination in the ways of life, etc., produces another difference, and a most important one in medico-legal practice, between •civil and criminal responsibility. The latter occupies, as it were, a higher position, and in not a few cases must be assumed to exist when the former must be deided. Of this a whole class of criminals affords an example ; I refer to those very youthful culprits who are in general as yet incapable of exercising the civil rights of life, and consequently possess no civil responsibility, while their iLLegal evil deeds are carried out with the most perfect consciousness of tlieii* punishable character and with all the unquestionable criteria of freedom of will, and they must therefore be declared to be criminally responsible. Both in the science of law and in the practical administration of justice, so far as I am acquainted with them, this doctrine is assumed as indisputable." (Casper's Handhooli of Forensic Medicine, vol. iv., part vi., chap, i., sec. 58.) At the present day, when the law no longer assumes the fact of the survival of the capacity of kno-s^ing good from evil, and consequently that of responsibility, unless the mental wreck extend to a condition of total insanity the inquiry becomes more subtile and difficult. An '■ in- divisible line " may separate, as Hale says, the conditions of total and partial insanity, but the line is still more "indivisible" separating the partial insanity that does fi-om the partial insanity that does not obscure this capacity, the obscuration being more complete and consequently more evident, in the night of total than in the clouds of partial insanity. For assuming that one partially insane is capable of a crinnnal intent, what problem is more perplexing than the question whether the disease did or did not affect the act? (Maudsley's Kesponsihiiifj/ in Mental Dis- ease, p. 109), and the further question whether '' conscious malice and mischief did mix with the insanity" ? (Erskine, Trial of Hadfield, supra.) The application of the canon of criminal responsibility finds its most ordinary expression in the question left to the jury, "Whether at the time of the committing of the act the party accused was laboring under 3uch a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or if he did know it that he did not know that he was doing what was wrong?" (^leXaghten's Case, supra.) The same canon has found a variety of expressions, as the fol- lowing : " Did he [the prisoner] know when he committed the act what 226 ^ SYSTEM OF LEGAL MEDICINE. tlie effect of it, if fatal, would be witli reference to tlie crime of murder f Did lie know that he was committiug- an offense against the laws of God and nature f " {Rex vs. Offord, 5 C. & P. 168.) " Whether the prisoner was laboring under tliat species of insanity which satisfies you that he was quite unaware of the nature, character, and consequence of the act he was committing, or, in other words, whether he was under the influence of a diseased mind and was really unconscious at the time he was com- mitting the act that it was a crime?" {Begina vs. Oxford, 9 C. & P. 525.) "■ If, on the other hand, he [the accused] well knew that his act would take away life, that that act was contrary to the law of God and punish- able by the law of the land" {Regina vs. TownJeg, 3 F. &F. 839), "the sin- gle question was whether, when he [the accused] committed the offense charged upon him, he had sufficient understanding to distinguish good from evil, right from VvTong, and that murder was a crime not only against the law of God but against the law of his country." (Belling- ham's Case, supra.) " Whether the accused at the time of doing the act was conscious that it was an act which he ought not to do." (Horn- blower, G. J., State vs. Bpencer, 1 Zab. 196.) As to the fli'st part of the canon, the knowledge of the nature and quality of the act, there can be little difficulty, as it contemplates a state of mind sufficiently obvious, one of complete overthrow, or of an illusion so complete as to render the mind insensible of the nature of the act. (Mr. Justice Le Blanc, Bowler's Case, supra.) " I can remember one case, and one case only," says Dr. Bucknill, " of a lunatic on trial for murder who really did not know the natiu'e and quality of the act which she had committed. It was that of a maniacal woman who had drowned her two children in the Exeter Canal. She was so mad when placed in the dock that Mr. Justice Cole- ridge, father to Lord Coleridge, saw that she was unfit to plead. He sent for his brother judge from the Nisi Prius Court, and well I remem- ber seeing the two judges standing in their robes of different color, and talking low to each other as they looked at the prisoner and formed their own judgment of her mental state, and Mr. Justice Coleridge or- dering her removal to the county asylum." Before the next assize she had completely recovered, and I again received an order to produce her in court, and Mr. Justice Coleridge (for he again was the judge), without takiug any evidence, directed the jury to find a verdict of 'not guilty^ on the ground of insanity, and upon that verdict having been given lie ordered her to be given to the care of her friends." (" On the Relation of Madness to Crime," American Journal of Insanity, vol. xl., p. 412.) Lord Brougham refers to this same condition of mental overthrow and com- plete illusion in the memorable debate on insanity and crime in the House of Lords (March 13, 1843, Hansard, vol. Ixvii., third series, p. 730) : "First of all, did the unfortunate person know what he was about? Did he actually know he was killing a man f Or did he think, peradvent- iire, he was destroying some evil spirit, or some bii'd or beast? If he did not know he was killing a human being — if he did not know wluit he was doing at all — if he was so idiotic as to be utterty and entirely ignorant of what he was about, he was no more subject to punishment, no more accountable to a human tribunal, than an animal." In the same debate (p. 721) Lord Lyndliurst instanced as an example of this conq;)lete illusion a ease taken from the Scotch reports, of a man tried for the murder of another by shooting him while he was goinp- across a moor. MEy^JL llKSrONSiniLITY IN CL'IMIAJL CASES. 227 It had been cLiimed tliat tlio prisoner labored under the dcbision tliat the man he shot was an evil spirit whom the Ahnighty had commanded liini to kill. As to the second part of the canon, that relating to the •conseionsness of tlie difference between riji^ht and wrong-, good and evil, the judges in their instructions would seem to reefer the (juestion of re- sponsibility to the consciousness of the individual in respect to abstract right and wrong; the right and wrong of the pai-ticular case; the right iind wrong of the moral law, the law of ( Jod, or the enactments of posi- tive law, the law of the land. B}^ some it has been (iontentled that the •canon refei's to the moral law alone {iSfafe vs. Spencer, supra) ; by others as strenuously, to the enactments of positive lav^, the fact of pun- ishability. This latter view appeals most strongly to those who seek in the law a precision perhaps unattainable ; for in relation to the conscious- ness, the existence of a fact as that of i)unishment is, as it were, a fixed point, when compared with the fluctuating conceptions of moral right and wrong that may be entertained by individuals. " He [Lord Broug- ham] knew the learned judges used the phrase with reference to the <}ommands of the law. They could only know one kind of right and wi'ong ; the right is when you act according to law, and the wrong is when you break it. . . . Distinguishing right from wrong meant a knowledge tliat the act the person was about to commit was punishable by the law." (Hansard's Debates, vol. Ixvii., p. 732.) Baron Bramwell strenuously maintained similar view^s before the select committee of the House of Commons upon the Homicide Law Amendment Act (Special Eep(u-t of Select Committee, vol. ix., p. 26, 1874): "A crazy fellow knows it is forbidden by law to knock out my brains, but has a notion it is morally right because I once tried a Fenian. Is it to be no crime? . . . He [Mr. Stephen, the author of the proposed act] says, ' I presume the notion arises from a disease affecting the crazy fellow's mind, where- by he is prevented from knowing that it is morally wrong to kill a judge who tried a Fenian; if not, the section does not apply; but making that assumption, I say distinctly no crime has been committed, because one of the conditions which law assumes in dealing with men is, that their moral feelings are on its side, to the extent, at all events, of understanding that acts of atrocious wickedness are atrociously wicked, and that a})art from the law they ought not to do them ; and this element is wanting in the case supposed.' He says further, '■ I do not believe in the possibility of neglecting this consideration in practice, as the following €ase will show.' ... It is the case of a man [James Hadfield] who sup- posed that if he could lie put to death he wt)uld save the world, and then he murders somebody, to get hanged in order to save the world. Mr. Stephen says, 'Would Baron Bramwell say that he ought to be hung? ' (I beg to say that is not the question. The question is, Whni rule are you to lay down ; are you to lay down a rule which would exclude his being- hung f) HarcUy, I think; but if not, wdiy notf 'He not only knows what he is doing, and that it is forbidden by law, but the fact that it is so forbidden is the very motive which makes him do it. . . . The man is under a monstrous delusion which prevents him from attending to or judging of the moral character of what he does, and ought no niore to be punished than a dreamer is blamed for what he does in his dreams.' I have put in answer to that, ' I would not have a law to except this case. which would necessarily except others that ought not to be excepted.' 228 ^ SYSTEM OF LEGAL MEDICINE. The question is, what rule you ought to lay down. In the particular case he cites, probably you would let the man oif being hung, but that he ought to be held guilty of murder I have no doubt ; whether I would hang him is another matter. And when Mr. Stephen says, ' One of the conditions which law assumes in deahng with men is, that their moral feelings are on its side, to the extent, at all events, of understanding that acts of atrocious wickedness are atrociously wicked, and that apart from the law they ought not to do them,' I deny that to my mind the law has anything to do with it ; but it simply tends to terrify the man, to threaten him; it cares not what his views are on the sul)ject, but says, 'That is a thing you should not do.' I do not quite understand that passage, and it would be very odd if it were true of moral and not of religious feel- ings ; which religious feelings have continually driven people into the commission of crime. . . . What you want to do is to frighten people,, to terrify them, and the way to try who ought to l^e punished, to my ■mind, is to try who ought to he threatened with punishment ; . . .if you can find out what man's mind is accessible to the influence of fear, you can find out the man you should punish, because those whom j^ou threaten you ought to punish, that it may not be h'ntum fulmen. You ought ta threaten every man sensible to the effect of a threat, and if this crazy fellow knows that what he thinks a virtuous or moral action is one which would ca.use him to be hung, I shall feel much more safety after having tried Fenians than I could otherwise feel." Sir James Mansfield instructed the jur}^ in Bellingham's Case (supra) that there was a third species of insanity in which the patient fancied the existence of injury and sought an opportunity of gi'atifying revenge by some hostile act. If such a person were capable in other respects of distin- guishing right from ^n'oiig, there was no excuse for any act of atrocity which he might commit under this description of derangement. This doc- trine placed obviously the criterion in the knowledge of right and "WTong, good and evil, in the abstract. The fallac}^ of this view became evident when the case of James Hadfield (supra) had shown the necessarj^ consid- eration of delusion as an element in the criterion of responsibility. ''' Few ihen," says Alison, " are mad about others or things, in general ; many about themselves. Although, therefore, the j^anel [prisoner or accused] understands perfectly the distinction of right and ^^a'ong•, yet if he labors, as is generally the case, under an illusion and deception as to his own particular case, and is thereb}^ disabled from appl3'ing it coirectly to his own conduct, he is in that state of mental alienation wliich renders him not criminally answerable for his actions." (Alison's Principles of the Criminal Laws of Scotland, chap, xxxv., sec. i. ; Hume's Commentaries on the Law of Scotland, vol. i., chap, i.) Of these questions an authoritative resolution is found in the answers given by the judges of England (with the excep)tion of Mi-. Justice Maule) to the questions put them by the House of Lords in consequence of the acquittal of Daniel McNaghten, indicted for the murder of Mr. Drummond, secretary of Sir Robert Peel. (10 01. & F. 200.) These judges, speaking through the Lord Chief -Jus- tice Tindal, gave the following answers : " The first question proposed by your lordships is this: 'What is the law respecting alleged crimes com- mitted by persons afflicted mth insane delusion in respect of one or more particular subjects or persons ; as, for instance, where at the time of the commission of the alleged crime the accused knew he was acting contrary MKNTAL RESrOXSIIirLTTY IN CRIMINAL CASUS. 220 to law, l)iit (lid the act eoinplained of with a view, under the influeiiec of insane delusion, of redressing- or revenging' some supposed grievance or injury, or of producing' soin(! su})pos('(l public, iM-nefitif' In answer to which (piestion, assuniing that your loi-dsliips' incjuiries are confined to those persons who labor under such 2)artial delusions only and are not in other respects insane, we are of opinion that, uotwithstantling the party accused did the act complained of with a view, under the influence of insane delusion, of redressing or revenging some supposed grievance or injury, or of producing some pul)lic benefit, he is nevertheless punishable according to the nature of the crime committed, if he knew at the time of committing such crime that he was acting contrary to the law; by which expression wo understand your lordships to mean the law of the land. Your lordships are pleased to inquire of us sectondly, 'What are the proi)er (Questions to be submitted to the jury where a person, alleged to be afflicted with insane delusion respecting one or more particular subjects or persons, is charged with the commission of a crime (murder, for example), and insanity is set up as a defense?' And thirdly, 'lu what terms ought the question to l)e left to the jury as to the prisoner's state of mind at the time when the act was committed f ' And as these two questions appear to us to be more conveniently answered together,, we have to submit our opinion to be, that the jurors ought to be told in all cases that every man is to be presumed to be sane and to possess a sufficient degree of reason to be responsible for his crimes, until the con- trary be proved to their satisfaction ; and that to establish a defense on the ground of insanity it must be clearly proved that, at the tune of the committing of the act, the party accused was laboring under such a de- fect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing what Avas wrong. The mode of putting the latter part of the question to the jury on these occasions has generally been, whether the accused at the time of doing the act knew the difference between right and wrong ; which mode, though rarely, if ever, leading to any mistake on the part of the jiiry, is not, as we conceive, so accurate when put gen- erally and in the abstract as when put with reference to the party's knowledge of i-ight and wi'ong in respect to the very act with which he is charged. If the question were to be put as to the knowledge of the accused solely and exclusively Avith reference to the law of the land, it might tend to confound the jur}^, by inducing them to believe that an actual knowledge of the law of the land was essential in order to lead to a conviction ; whereas the law is administered upon the principle that everj^ one nuist be taken conclusively to know it, without proof that he does know it. If the accused was conscious that the act was one which he ought not to do, and if that act was at the same time contrai-y to the law of the land, he is punishable ; and the usual course, therefore, has b(K'n to leave the (|uestioii to the jury, whether the party accused had a sufficient degree of reason to know that he was doing an act that was wrong; and this course we think is correct, accompanied Avith such ob- servations and explanations as the circumstances of each particular case may require. The fourth question which your lordships have j)roposed to us is this: 'If a person under an insane delusion as to existing facts connnits an oifense in consequence thereof, is he thereby excused ? ' To which question the answer must, of course, depend on the nature of the 230 ^ SYSTEM OF LEGAL MEDICINE. delusion ; but, making tlie same assumption as we did before, namely, tliat lie labors under sucli partial delusion only, and is not in other re- spects insane, we think he must be considered in the same situation as to responsibility as if the facts with respect to which the delusion exists were real. For example, if, under the influence of his delusion, he sup- poses another man to be in the act of attempting to take away his life, and he kills that hian, as he supposes, in self-defense, he would be exempt from punishment. If his delusion was that the deceased had inflicted a serioiis injury to his character and fortune and he killed him in revenge for such supposed injury, he would be liable to punishment." The questions put to the judges were general in their terms, ha\ing reference to the facts of no particular case, and Mr. Justice Maide ex- pressed a fear (p. 204) that the answers might, from their necessary gen- erahty, prove an embarrassment in the administration of justice. There was also a cpiestion whether the lords had a constitutional right to put them under existing circumstances. Be this as it may, they are regarded as an authoritative exposition of the law by the com-ts of THE UXITED STATES. U. 8. vs. Solmes, 1 Chf. 98 ; U. S. vs. Xiclwlas ScJiuJfz, 6 MacL. 121 ; U. 8. vs. McGIue, 1 Curt. 1 ; as well as by the coiu'ts of the following of the United States of America : ARKANSAS. Casaf vs. State, 40 Ai-k. 511. CALIFORNIA. Peo2)le vs. Holson, 17 Cal. 424 ; Peo2}Je vs. Coffman, 24 Cal. 230 ; People vs. McDonnell, 47 Cal. 134 ; People vs. Ferris, 55 Cal. 588 ; People vs. Pico, 62 Cal. 50; People vs. Hoin, 62 Cal. 120; People vs. Blalie, 65 Cal. 275. DELAWARE. State YB.Windsor, 5 Harr. (Del.) 512. GEORGIA. Poherts vs. State, 3 Geo. 310 ; Loyd vs. State, 45 Greo. 57 ; BrinJcley vs. State, 58 Geo. 296. IDAHO. People vs. Walter, 1 Ida. 386. KANSAS. State vs. Malm, 25 Kan. 182. MAINE. State vs. Lawrence, 57 Mai. 574. JIASSACHUSETTS. Commonwealth vs. Rogers, Jr., 7 Mete. 500. MENTAL nESPOXSinilATy IX CniMIXJL CASES. 231 lyilNNESOTA. State vs. Shippey, 10 Minn. 223 ; State vs. Gut, 13 Minn. 341. MSSOURI. State vs. Ruting, 21 Mo. 4G4 ; State vs. Redemeier, 71 Mo. 173 ; State vs. i;r/>, 74 Mo. 199 ; State vs. Kotovshy, 74 Mo. 247. NEBRASIvA. Wright vs. People, 4 Neb. 407 ; Ifair^ vs. People, 11 Neb. 537 ; Bar^ vs. mate, 14 Neb. 573. NEVADA. State vs. ie?m, 20 Nev. 333. NEW JERSEY. /8'tofe vs. Spencer, 1 Zab. 196. NEW YORK. Freeman vs. People, 4 Den. 9 ; TT^/JZ/.s vs. People, 32 N. Y. 715 ; Flana- gan vs. People, 52 N. Y. 467 ; Moett vs. Peojile of the State of Xew Yorl; 85 N. Y. 3735 Walker vs. Peojjle of the State of Keiv York, 88 N. Y. 81. NORTH CAROLINA. State vs. Brandon, 8 Jones (L.) 463 ; State vs. Raijtvard, Pliil. N. C. 376. OHIO. Clark vs. The State, 12 O. 483. OREGON. State of Oregon vs. Murray, 11 Or. 413. TENNESSEE, Rove vs. T/?^ /S'frtff, 3 Heisk. 348. TEXAS. Thomas vs. State, 40 Tex. 60. THE DISTRICT OF COLOIBIA. U. S. vs. Guiteau, 1 Mackey, 498 ; U. S. vs. Xee, 4 Mackey, 489 ; Z7. S. vs. €7rtr/.-f, 2 Cranch, D. C. 158. Of an authority almost equal to these answers is the famous charg3 of Cliief-Justice Shaw in the case of Commonwealth vs. Rogers (supra), which has been repeated almost verliatim in the instructions given to juries by the judges in man\' States of the American Union. The law, in its inquiry as to the fact of the existence of the capacity to know right from wrong, good from evil, has given, as it were, a legal 232 A SYSTEM OF LEGAL MEDICINE. recognition to certain facts which, as the indicia of the existence of this capacity, it regards as leading symptoms in the diagnosis of criminal responsibility. As an all-controlling principle may be considered the dogma (which is without exception) that the fact of insanity cannot be inferred intrinsically from the nature of the act itself, but must be proved extrinsically, although its atrocious character may support such extrinsic proof of the fact of insanity. {Laros vs. Commonwealth, 84 Pa, St. 200.) 1. Evidences of Design and of the Adaptation of Means to an End. In the early cases great stress is laid upon any fact or facts tending- to show that the accused had a steady and resolute design and used all proper means to effect it. (Trial of Edward Arnold, supra ; Trial of Earl Ferrers, 19 How. St. Tr. 886 ; Trial of James Hadfield, supra.) At that time, when the possession of any memory and understanding of any of the mind's essential constituents argued the existence of the capacity to know right from wrong, good from evil, and consequently that of responsibility, it was considered an obvious consequence that the capacity to form a design, one of the most ordinary proofs of the pos- session of reason, should be considered a decisive circumstance. At the present day this same capacit}!' is considered a controlling element in the diagnosis of responsibility. In the case of The People vs. Henry Camel, the defense being insanity, Mr. Justice Edmonds instructed the jury that the capacity to form an intention, and of devising the means of execut- ing it, would warrant a conviction. (2 Edm. Sel. Ca. 200.) The New York Court of Appeals held in the recent case of The People vs. Earlier (115 N. Y. 475) that " the facts relied upon by the prosecution to show the adaptation of means to ends , . . are factors of importance upon the question of the defendant's legal responsibility." Although abstract and a pmori reasoning might lead one naturally to infer that the capacity to form a design, and the use of means suited to its accomplishment, would conclusively prove the existence of a mind "undisturbed, or one sufficiently so as to impose responsibility, a closer observation of the characteristics of insanity has had a tendency to dis- credit the so-called " method in madness." It has been shown that cun- ning and contrivance are of the qualities least frequently affected by in- sanity, and it is considered, among the Continental jurists at least, that the test has little diagnostic value. In their opinion the examination of the systematic planning of a deed can only be valuable when it tends to indicate a condition of irresponsibility — "when these plans and prep- arations themselves evince the stamp of a confused intellect, and betray the hazy consciousness, the mental darkness in which the culprit was in- volved." (Casper's Handhooh of Forensic Medicine, vol. iv., part vi., chap, i., sec. 62 ; " Review of Mittermaier on the Excuse of Insanity," American Jurist, vol. xxii., p. 312.) 2. The Appreciation of the Nature of the Act and its Consequences. From the earliest times the fact of responsibility has been inferred from any circumstance that might evidence the possession of the above capacity. Of this tb^' ^-"o cases cited by Hale are examples — the one^ " an. MENTAL llESroysiniLITT IN CJinilNAL CAHES. 233 infaut within ag'e that liad killed his companion and hid himself was presently hang-ed, for it appeared by his hiding- he could discern Ijctween go(jd and evil ; " the other, " an infant of the age of nine years killed an infant of the like age ; he confessed the felony, and upon examinati(jn it was found he hid the blood and the body; the justices held he ought to be hanged." (1 Hale, P. C, 2G, 27.) In the trial of Lord Ferrers (supra) the ease of the Crown, as set forth by the solicitor-general, was mainh- an appli- cation of this and the j)receding criterion. As evidences of Lord Ferrers's knowledge of the consequences of his act, the solicitor- genei*al emphasized the sending for a surgeon, and his inquiry whether the steward Johnson, whom he had shot, would live or die ; his statement to Johnson's daugh- ter that he feared a pr<\-, supra ; Conimonu^eaUh y&. Buccieri, sixpva,.) In the application of this criterion a distinction has been drawn between mere absence of evi- dence of the existence of motive and affirmative evidence of its non-exist- ence, the latter only being considered to be a factor in the question as to the fact of responsibility. [Regina vs. Law, 2 F. & F. 836, note a.) Nor can an inference as to the existence of an insane irresistible impulse be made per viam exclusionis from the concmTcnce of the apparent absence of motive and the atrocity of the deed, for according to Baron Rolfe [Regina vs. StoA'es, 3 C. & K. 18o) it is considered dangerous ground to take to say that a man must be insane because men fail to discern the motive of his act ; and according to Baron Bramwell [Regina vs. Haynes, 1 F. & F. 666) motives exist uukno^Ti and innumerable which might prompt the act. Any evidence as to the non-existence of motive has been held imma- terial when a knowledge of the natm-e of the act is coupled with evident intention to do it. [Regina vs. Dixon, 11 Cox, C. C. 341.) It has been determined that evidence of the absence of motive is an essential factor in considering the responsibility of epileptics [People vs. Barber, supra) ; but on the part of medical science it has been maintained that evidence of the existence of such motive is not decisive. "These patients," it is said, " are controlled in the midst of their passions by an appreciable motive, which has for them a reality ; but we should ask ourselves if in a state of sanity such a motive would arise, and, above all, if it would be predominant enough to control reason. Thus the motive and premedita- tion, which seem under such circumstances to have dictated the criminal act, are insufficient to establish peremptorily the integrity of free-will, and consequently the existence of guilt." ("Criminal Responsibility of Epileptics as Illustrated by the Case of Da^id Montgomery," by M. G. Echeverria, American Jotirnal of Insanity, vol. xxix., p. 341.) 4. The Acting upon Existing Facts, the Rum an Passion being Directed to its Proper Object. The consideration of this criterion forms part of the subject of DELUSIONS. From the fact of the essential characteristic of partial insanity being its limitation to one or more points, the most ordinary evidence of which MESTAL nESrOX/^IIilLITY IN CRIMINAL CASES. 235 is tlie existence of one or more delusions, the acquittal of James Had- field (sui)ra) gave a legal recognition to the theory that delusion, wlien there is no frenzy or raving madness, is of the very essence of insanity. In his memorable defense Erskine maintained that the premises from which such insane persons reason, when witljin the range of the malady, were uniformly false, not from any defect of knowledge or judgment, but because a delusive image, the inseparable companion of real insanity, was thrust upon the subjugated understanding, incapable of resistance because unconscious of attack. In his opinion, when delusion could not be predicated of a man standing for life or death for a crime, he ought not to be acquitted. These views, which are not consonant with the sci- ence of the day ('' The Legal Doctrine of ResponsibiUty in Cases of Insan- ity Connected with Alleged Criminal Acts," by Forbes Winslow, 1 Jurid- ical Sociefi/ Papers, 595), reflected the medical ideas of the time, and above all the metaphysical speculations of Locke, the predominant philo- sophical authority, who thus distinguished between idiocy and insanity : " In fine, the defect in naturals seems to proceed from want of quickness, activity, and motion in the intellectual faculties, whereby they are de- prived of reason ; whereas madmen, on the other side, seem to suffer by the other extreme, for they do not appear to me to have lost the faculty of reasoning, but, having joined together some ideas very ■\va"ongly, they mistake them for truths, and they err as men do that argue right from wi-ong principles, for by the violence of theii* imaginations, having taken their fancies for realities, they make right deductions from them. Thus you shall fijid a distracted man fancying himself a king, with a right in- ference requiring suitable attendance, respect, obedience; others, who have thought themselves made of glass, have used the caution necessar}^ to preserve such brittle bodies. Hence it comes to pass that a man who is very sober, and of a i-ight understanding in all other things, may in one particular be as frantic as any in bedlam, if, either by any sudden very strong impression or long fixing his fancy upon one sort of thoughts, incoherent ideas have been cemented together so powerfully as to remain united. But there are degrees of madness, as of folly; the disorderly jumbling of ideas together is in some more, some less. In short, herein seems to lie the difference between idiots and madmen : tliat madmen put wi'ong ideas together and so make wi-ong propositions, but argue and rea- son right from them ; but idiots make very few or no propositions, and reason scarce at all." [Essay on the Human Understanding, book ii., chap, xi., sec. 13.) These views have had a predominant influence upon the law in all its branches. In the leading case of Deiv vs. Clark tO Clarh (3 Add. Eee. 79), Sir John NiclioU held that the true criterion, the true test, of the absence or presence of insanity was the absence or presence of delu- sion. At a recent date. Lord Denman instructed a jury that to say a man was irresponsible without positive pi'oof of any act to show that he was laboring under soine delusion seemed to him to be a presumption of knowledge which none but the great Creator himself could possess. {Regitia vs. Smith, "Plea of Insanity in Criminal Cases," 5 Journal of PsychoJogical Medicine and Mental Pathologg, p. 103.) And Baron Martin, in Begina vs. Townley (supra), held that what the law meant by an insane man was a man who acted under delusions and supposed a state of things to exist which did not exist, and acted thereupon. I"^pon this basis of delusion as the indispensable and essential characteristic of insanity, '236 ^ SYSTEM OF LEGAL MEDICINE. Erskine formulated a criterion of responsibility (No. 4, supra) which, al- though it has had a certain weight, cannot be said to have successfully withstood the assaults of adverse criticism. "The principle contended for by this eminent person is that when a maniac commits a crime under the influence of an impression which is entii'ely ^dsionary, and purely the hallucination of insanity, he is not the object of punishment ; but that, though lie ma}^ have shown insanity in other things, he is liable to pun- ishment if the impression under which he acted was true, and the human passion arising out of it was directed to its proper object. He illustrates this principle by contrasting the case pf Hadfield with that of Lord Fer- rers. Hadfield had taken a fancy that the end of the world was at hand, and that the death of his Majesty [King George III.] was in some way connected with important events which were about to take place. Lord Ferrers, after showing various indications of insanity, murdered a man against whom he was known to harbor deep-rooted resentment on ac- count of real transactions in which that individual had rendered himself obnoxious to him. The former, therefore, is considered as an example of a pure hallucination of insanity ; the latter as one of human passion founded upon real events and directed to its proper object. . . . There can be no doubt of the first of his propositions, that a person acting under the piu'e hallucination of insanity in regard to impressions which are entirely unfounded is not the object of punishment. But the converse does not seem to follow, namely, that the man becomes an object of pun- ishment merely because the impression was founded on fact and because there was a human passion directed to its proper object. For it is among the characters of insanity not only to call up impressions which are entirely visionary, but also to distort and exaggerate those which are true, and to cany them to consequences which they do not warrant in the estimation of a sound mind. A person, for instance, who has suffered a loss in business which does not affect his circumstances in any important degree may imagine, under an influence of hallucination, that he is a ruined man and that his family is reduced to beggary. Now were a wealthy man under the influence of such hallucination to commit an outrage on a person who had defrauded him of a trifling sum, the case would afford the character mentioned by Erskine, namely, human pas- sion founded upon real events and directed to its proper object; but no one probably would doubt for a moment that the process was as much the result of insanity as if the impression had been entu-ely visionary." (Abercrombie on The Intellectual Powers, part iii., sec. iv., p. 2G5.) This is confirmed by the affirmation of medical science that it is one of the well-known characteristics of insanity for persons to labor under delu- sions connected with and originating in actual circumstances. ("The Legal Doctrine of Responsibility in Cases of Insanity Connected with Alleged Criminal Acts," by Forbes Wiiislow, 1 Juridical Society Papers, 605.) It would seem, therefore, that in deciding a doubtful case a jurj^ ought not to be guided b_y the circumstances of the ease exclusivel_y, but by evidence of insanity in other things as well. This seems actually to be the rule, for many verdicts given b}^ juries involve a practical rejec- tion of this criterion. The recent acquittal of John Daley on the ground of insanity, tried in the city of Washington for the murder of a real- estate agent named Kennedy, affords us a striking instance among many. (" A Judicial Advance — the Daley Case," by W. W. Godding, M.D., Anieri- MENTAL HESI'().\SIIIIL1TY IN CRIMINAL CASES. 237 can Jonnud of Insanlijiy vol. xlv., p. 191, Octohcr, ISSft.) Tliis nasc liaci a twofold aspect : a delusion of poisoning' and surveillance, and a real resentment founded upon existing facts. Daley, an Ii-islunan of about fift}' years of age, liad been a lay brt^tlier in a Catholic college. While an innuite there he applied for medical advice to the clergyman iu charge, who procured medicine for him. From certain circumstances he became convinced that the drug given him had been changed by the ijriest in order to poison him and get thereby the possession of his money. While the amount of the drug taken had not been enough to kill him, it had undermined his health, producing a '' gum exudation over his whole body," which continued to the time of the murder, and his life was ruined in consequence. On his leaving the college, it was only to be shadowed by " detectives of the order," an order, apparently, of Catholic priests. He saw them when he visited Washington in 1878, and again in 'the following 5^ear. lie made his home iu Washington in the year 1882, and about that time comes in his one business transaction with the deceased. Previous to this he had given sums of money to his father, which had been expended in the purchase from Kennedy of a lot in Washington. Tlie facts in regard to this transaction appear to have been : that the lot of land so bought had again passed into the hands of Kennedy, he holding it in trust. Daley, !Sr., had arranged in 1882 to purchase it for $900, making monthly payments for the same, but he died before the completion of such payments. Kennedy paid the funeral expenses, charging them against the account. When John Daley de- manded a settlement, Kennedy, after examining his books, tokl him there was nothing due him. The lawyer whom Daley subsequently con- sulted advised him to settle his claim for $100 if he could get it. Ken- nedy finally paid him $50 by a check, taking Daley's receipt in full of all demands. The books of the deceased, produced in court, showed a balance due the estate at that time. Kennedy sul)sequeutly sold this same lot in 1886 for more than the sum of $5000, as recorded. This latter fact probably came to the knowledge of Daley. It is certain that he alwaj^s believed that Kennedy had " beat him " in the transaction, and, though he accepted the check for $50 in full payment, doubtless^ considered he had been defrauded of money justly due him. Daley, subsequently laboring under this delusion as to his persecution by the " detectives of the order," purchased a pistol for the purpose of shooting one Elliott, an apothecary of Washington, whom he delusivel}^ imagined to be one of those detectives. This pistol he sold. At a later daj^ meet- ing Elliott near the Capitol, he endeavored to strike him on the head with a stone, and failing in his attempt, he assaulted him with his fists. This led to his imprisonment. Upon his release, having met Ken- iiedij in the streets of Washington, he plunged a knife into his abdo- men. Some time after his arrest Daley stated that "he and Mr. Ken- nedy had had a dispute over a real-estate matter and he had got even with him." The case, from the standpoint of the alienist, was interest- ing but puzzling. The commission of experts reported that the accused was undoubtedly insane, but that they were unable to connect the homi- cide with the delusion of j)oisoning and surveillance that had prompted the assault on the apothecary Elliott, nor were they satisfied that his ideas respecting the wrong done him by Kennedy were delusions in the .same sense as the above. The State practically conceded the fact of the 238 ^ SYSTEM OF LEGAL MEDICINE. insanity, and gave the case to ttie jury on tlie failnre to connect the homicide with the dehision, its theory being that the killing was founded upon a real resentment, the liuman passion being directed to its proper object. The jury, in their verdict of acquittal, were undoubtedly led to this conclusion by the evidence of insanity in other things. The leading canon in the matter of delusion is, that the act should be the offspring- of the delusion itself. " Where the connection is doubtful," says Erskine (Trial of Hadfield, supra), " the judgment shoidd certainly be most in- dulgent, from the great difficulty of diving into the secret sources of a disordered mind ; but still I think that, as a doctrine of law, the delusion and the act should be connected." Tliis doctrine as an abstract proposi- tion may be beyond criticism, for medical science admits that " if the delusion be limited to one or to a few closely kindred subjects, and if it be of long standing, it perhaps is possible for persons so afflicted to be capable of exercising theii' judgment upon matters not immediately con- nected with the delusion." ("AuAddi-ess on the Present Relation of Insanity to the Criminal Law of England," by W. Orange, M.D., British 2Iedic(d Journal of October 20, 1887.) From this it would follow, as a legal consequence, that the same rule prevailing in questions as to civil competency should be apphed to criminal responsibihty {BauJiS vs. Good fellow, L. R. 5 Q. B. 549) — that the mere existence of an insane delusion, which does not in fact influence particular parts of the conduct of the person afflicted by it, should have no effect upon their legal char- acter. (Stephen's History of the Criminal Law of England, chap, xix., p. 162.) The connection, however, between the delusion and the act itself is a question of fact, one presenting the greatest difficulty, inasmuch as a connection not apparent to the sane mind, nor even conceivable by it, may exist in the insane one, and " the exact bearing of any delusion can often onl}^ be ascertained with certainty through the statements of the accused himseK ; and when, either on account of increasing dementia, or from any other cause, the accused is disinclined to enter into conversa- tion, the point must necessarily remain in the region of conjecture and probabLlit3^" (The Address of Dr. Orange, supra.) As illustrations. Dr. Orange, in his address, referred to above, instanced several cases. " In the case of the American surgeon who shot a man in the streets of London about four years ago the connection between the delusion and the act was very strikingly marked, although this connection was not made out at the trial. The poor man who was the victim was on his way to his work at the Lion Brewery between tlu'ce and four o'clock in the morning, when he was suddenly shot dead, his assailant firing four times at him. His assailant then gave himself up quietly to the i)olice, sapng that they would soon find out he was quite justified in what he had done. After he became an inmate of Broadmoor, he gave me a most vivid account of the matter from his point of view. He was under a delusion that he was a victim of conspiracy, and that his enemies had determined to slowly torture him to death by sending one of their num- ber into his bedroom in the middle of the night to wake him out of his sleep. He provided himself in consecj^uence with a revolver, which he took to bed with him, intending, as he said, to shoot his persecutor while actually in his bedroom. He woke up with a start in the usual manner during the night, and imagined that he saw his persecutor at the foot of hig bed; but before he could lay his hands on his revolver and take aim MESIAL nESl'OySllillATy IX ClUMIXJL CASES. 231) he thought he saw the man pass out through the bedroom door. lie foUowed as (|uiekly as possil)k' and fiineied he saw the man on the stair- case ; but again before he coukl aim the man liad, as he thulse over which his will had no power f If so, they nnist acquit him on the ground of insanity." (Review of "History of the Criminal Law of England,'' by Stephen, f/o«;-- nal of Mental Science, vol. xxix., p. 258.) So also in a recent case, Mr. Jus- tice Lawrence put thus the question to the jury : " Was the prisoner un- able to control his actions in consequence of disordered mind?" (The Duncan Case, Journal of Mental Science, vol. xxxvii., p. 562.) As the lead- ing canon, so have the subordinate criteria in relation to delusions met with adverse and destructive criticism. As has been said, these answers of the judges have for their basis the assmnption that the accused is " not in other respects insane " ; that the effect of the delusion is to ^n'oduce an intellectual error as to an existing fact, the limits of which are found within the delusion itself. It is held by the most distinguished authority that the fact of an illegal act being conunitted from the point of view of a fixed delusion is in itself a proof that the reason of the accused has lost control of the fixed idea, and that the delusion itself has ceased to be a limited one. (Casper's Handhool) of Forensic Medicine, part vi., vol. iv., chap, ii., sec. 80.) Be this as it may. the answers, even upon their as- sumption of a partial or hniited delusion, have not met ^itli acquies- cence ; and adverse criticism in support of its position as to their intrinsic unreasonableness urges as objections : the arbitrary imposition of limits upon a disease so subtile and mysterious as that of insanity 5 the at- tributing to madness the delusive imaginary fact, and to sanity the emotion or passion arising out of that fact; the judgment of these emotions or passions from a standpoint of sanity, by the exaction from the accused of a sane conduct in reference to them, thus eliminating- any influence of the disease upon the emotions and the will. {State vs. Jones, 60 N. H. 369 ; Parsons vs. State, 81 Ala. 577.) This elimination, it is claimed, essentially contradicts the pathology of delusions as symp- toms of mental derangement. Medical science assures us that '^ a delu- sion . . . never, or hardly ever, stands alone, but is in aU cases the result of a disease of the brain, wdiich interferes more or less with every function of the mind, which falsifies aU the emotions, alters in an unaccountable way the natural weight of motives of conduct, weakens the will, and sometimes, without giving the patient false impressions of external facts, so enfeebles every part of his mind that he sees and feels and acts -\Wth regard to real things as a sane man does with regard to what he sup- poses himself to see in a dream. . . . Suppose, for instance, that by i-ea- son of the disease of the brain a man's mind is filled with delusions which, if true, woidd not justify or excuse his proposed act, but which in them- selves are so wild and astonishing as to make it impossil)le for him to reason about them calmly, or to reason cahnly upon matters connected with them. Suppose, too, that the succession of insane thoughts of one 250 A systjEM of legal medlcine, kind and another is so rapid as to confuse liim ; and finally suppose that his will is weakened by his disease, that he is unequal to the effort of calni sustained thoug'ht upon any subject, and especially upon subjects connected with his delusion — can he be said to know or have a capacity of knoAving that the act which he proposes to do is wrong?" (Stephen's Historij of the Crimmal Law of England , vol. ii., chap, xix., pj). 157, 164.) As a solution, Sir J. F. J. Stephen would construe the answers of the judges in a broader and, as it were, a " non-natural " sense : the word "know" including, in his opinion, not knowledge only, but the power of controlling the conduct as well: "Knowledge and power are the constit- uent elements of all voluntary action, and if either is seriously impaired the other is disabled. It is as true that a man who cannot control him- self does not know the nature of liis acts as that a man who does not know the nature of his acts is incapable of self-control." His proposition is, " that, if it is not, it ought to be the law of England that no act is a crime if the person who does it is at the time when it is done prevented either by defective mental power or by any disease affectinr his mind from controlling his own conduct, unless the absence of the power of self-control has been produced by his own default." (Stephen's History of the Criminal Laiv of England, vol. ii., chap, xix., p. 168.) In the opinion of the Lord Chief -Justice Cockburn, the doubts and difficulties suggested by the answers of the judges have been due to a construction too wide and general, and to their not having been ajDplied strictly with reference to the questions put : " Among the functions of the human mind liable to be perverted by disease is, as all scientific writers on insanity are agi'eed, the human will : which sometimes becomes the slave of maniacal impulses, which it is unable to resist. Among the different forms of madness by which the will is liable to be thus affected is that which is known by the name of homicidal mania, or when it compels a person to self-destruction, suicidal mania. That the will is liable to be thus maniac- ally affected, and so to be swayed by impulses which it is unable to resist, is a point on which writers on mental pathology are agreed. Instances have been known in which lunatic patients have been periodically thus affected, and, conscious of the approach of the maniacal condition, have requested to l)e placed under restraint. Murders for which no motive could be suggested, sometimes of childi-en by their own mother, self-mur- der, equally without adequate motive, by men of religious character, can often only be thus accounted for. Ought persons, who, thus afflicted, commit crimes, to be punished as though they were of sound mind and capable of the self-restraint wdiich the sense of moral right and wrong or the fear of the law imposes upon others more happily constituted ? The point cannot as yet be said to have been authoritatively determined. The language of the judges in the House of Lords has, no doubt, been repeated as of general application, but erroneously. Their answers had reference to the sj>eciftc questions put them by the House, the language of whic'h was in these terms : ' What is the law respecting alleged crimes committed by persons afflicted with insane delusions in respect of one or more particular suljjects or persons?' The answer is restricted to the specific question so put. 'Assuming,' it begins, Hhat your inquiries are confined to those persons who labor under such partial delusion only and are not in other respects insane, we are of opinion,' etc. — the answer thus excluding any other form of insanity save that of partial delusion, MENTAL UKsroXsiIllLirv IX CIUMINAL CASES. 2~)1 and c(>us('(jU('Jitly not toucliing' the case of mania, to wliicli I am at pres- ent directing attention. Fnrther questions are put as to the questions to be put to the jury wlien a person liaving" insane dehisions is charged with (u-ime, and insanity is set up as a defense, find the answers, as l)e- fore, have refereuct^ t>idy to tlie questions put, tljat is to say, as to the effect of insane dehisions as a defense. Tlic point has not come under judicial discussion in a case which really raised the cpiestion. The near- est approach to it was in the case of lipgina vs. JJiirfoii, reported in 3 F. & F. 772, where the prisoner, a hid of eighteen, had murdered a boy, con- fessing the fact afterward, and accounting for it by saying ' he had made up his mind to murder some one, as he was tired of life.' There was insanity in the boy's family, liis mother having been twice confined in a lunatic asylum, but the defense set up being homicidal mania and the want of self-control, there was no evidence of the latter in anything but the fact itself. The summing up of the learned judge, Mr. Justice Wight- man, cannot, I think, be considered as satisfactory. While depreciating- the doctrine of homicidal nuxnia as a highly dangerous doctrine, he went the length of saying, founding himself upon the supposed doctrine of the judges, which he mistook, that to entitle a man to be acquitted on the ground of insanity there must be ' delusion ' and ' inability to distinguish right from wrong,' whereas the question whether mania accompanied by insane impulses might afford a defense was not submitted to the judges or involved in their answers. The question whether under the influence of mental disease the human will may become subject to impulses which it is unable to resist, and upon which even the fear of death will not oper- ate as a restraint, is not one for lawyers to disposa of dogmatically^ as they often do, but one which, as a question of patliological science, it is for men conversant with that science to decide. If the fact is estal)- lished, as I believe it to be, it is for the enlightened and philosophic law- giver, in the interest of justice and humanity on the one hand and of so- ciety on the other, to determine whether an act done in such a condition of the mind shall subject a man to punishment." (Letter relating to the Crim- inal Code, Indictable Offenses Bill, Papers, vol. liv., p. 232.) With these latter views ai'e the Continental jurists agreed. With them the " faculty of choosing between good and evil," or "the power to act with freedom," is not necessarily included in the capacity to know right from wrong; Mitter- maier holding that two conditions are required to constitute the freedom of the will, which is essential to responsibility, namely, a knowledge of good and evil and the faculty of choosing between them. (Review of Mittermaier on "The Excuse of Insanity," Amerkmi Jurist, vol. xxii., pp. 312, 313; Casper's Haiulhooli of Forensic Medicine, vol. iv., part vi., chap, ii., sec. 80.) The effect of mental disease upon the emotions and the will, and the consequent power of controlhng the conduct, are recognized as essential elements of responsibility in ALABAMA. By the loss of the power of choosing between right and wi'ong through the duress of mental disease. Parsons vs. State, 81 Ala. 577. CONNECTICUT. By the irresistible impulse arising from disease. State vs. Johnson, 40 Conn. 136. 252 A STSTUM OF LEGAL MEDICINE. ILLINOIS. By an uncontrollable impulse to do the act cliarged, which deprives the accused of the power to choose between the right and the wrong, Hopps vs. People, 31 lU. 385. INDIANA. By the loss of the power of self-control through mental disease. Stevens vs. State, 31 Ind. 485 ; Bradley vs. State, 31 Ind. 492 ; Conway vs. State, 118 Ind. 482. IOWA. By an uncontrollable and irresistible impulse arising from mental disease. State vs. Felter, 25 Iowa, 67 ; State vs. Meivherter, 46 Iowa, 88. MICHIGAN, By the loss from insanity of the power to resist temptation to violate the law. People vs. Finley, 38 Mich. 482, PENNSYLVANIA, By the loss through disease of the power of self-control and the free- dom of moral action, '' the morbid propensity existing to such an extent as to subjugate the intellect, control the will, and render it impossible to do otherwise than yield thereto." Taylor vs. Commonwealth, 109 Pa. St. 262 ; Commonu'eaWi vs. Winnemore, 1 Brewst. 356 ; Ortwein vs. Common- wealth, 76 Pa. St. 414 : Broivn vs. Commomcealth, 78 Pa. St. 122. MORAL INSANITY. The impulses hitherto referred to have been of two kinds. The one, overwhelming the reason, conscience, and judgment, obliterates or ob- scures the capacity to distinguish between right and wrong. {Common- ivealth vs. Rogers, Jr., 7 Mete. 500 ; Cunningham vs. State, 56 Miss. 269 ; People vs. S])ragne, 2 Park, C. R. Cases, 43 ; Eegma vs. Barton, 3 C. C. 277.) The other, irrespective of its influence upon this same capacity, so subjugates the will as to deprive the subject of the power of self-control — the freedom of moral action. This latter impulse being the undoubted offspring and product of mental derangement — of intellectual insanity — a recognition of it as an element of responsibility does not involve as a necessary consequence an acquiescence in the theory of the so-called ^^ moral or emotional insanity." This theory, having its origin in a sup- posed lesion of the will, apart from that of the understanding, in the pre- sumed existence of an instinctive and abstract rage or mania withoiit delirium, " nn emportement maniaque sans delire,''' was extended by other theorists to the discovery and description of a disorder called "moral in- sanity," of which the symptoms were only displayed in the state of the feelings, affections, temper, and in the habits and conduct of the indi- vidual, or in the exercise of those mental faculties which are termed the active and moral powers of the mind. In this alleged disorder it was assumed that there was no discoverable illusion or hallucination, or MENTAL ItESPONSIBILITY IN CRIMINAL CASES. 253 any symptom characteristic of monomania or intellectual insanity — in a word,' that " an insanity in conduct " existed separately and distinct from the insanity in ideas. (Prichard's Forms of Ltsaiiifij, sec. v.) Dr. Mauds- lev, reeog-nizing' this alleged form under the general name of " affective insanity " — that is, insanity without delusion, or insanity of feeling and action— subdivides it into the two classes of impulhiive and moral insan- ity ; the former being mental disease whereby tlie sufferer, with(nit i)as- si'on, delusion, or motive, is driven independently of the will by blind instinctive impulses ; the latter a disorder of the mind without illusion, delusion, or hallucination, the symptoms of which being mainly exhibited in a i)erver.sion of those mental faculties which are usually called the act- ive and moral powers. {ResponsiMlifji in Monial Disease, chiv^. y.) Dr. Eay and others, insisting upon the existence of a moral mania as contra- distinguished from the intellectual form, distinguished between general moral mania and partial moral manias, the latter being evidenced by spe- cific morbid impulses which are in these cases presumably the exclusive and essential symptoms of the existing insanity : such as kleptomania, an irresistible impulse to steal ; pyromania, an ii-resistible impulse to burn and destroy, erotomania and nymphomania, irresistible impulses to .sexual excess ; homicidal mania, an irresistilile impulse to kill ; suicidal mania, an irresistible impulse to self-destruction. (Ray's Medical Jiiris- jyrudence of Insanitu, chap, vii.) As in the opinion of the medical experts there were e"vidences of mental derangement in the case of Charles P. Huntington, who was tried for forgery at the G-eneral Sessions of the county of New York in the year 1856, the diseased tendency to " make paper," that is, forge commercial paper, may not perhaps be considered an addition to the above classifications. (Trial of Charles P. Hunting- ton, Testimony of Willard Parker, M.D., p. 253.) It is obvious that these theories, the " excuse of an irresistible impulse coexisting with the full possession of reasoning powers" (Baron Parke, Regina vs. Barton, supra), can find no countenance in the law of England, "which does not admit into its criterion of responsibility the element of impulse, even though that impulse be the undoubted offspring of inteUect- nal derangement. A recognition no more ample is given b}' the courts of those American States that admit an impairment by disease of the freedom of the will, the disease being presumably a form of intellectual insanity. {Parsons vs. State, supra.) Some few cases which cannot be considered as authorities have gone a step beyond. At an early day in Pennsylvania Chief-Justice Gil^son affirmed [Conunonwealtli vs. Mosler, 4 Pa. St. 26-4) that insanity was either meutal or moral, the latter consist- ing of an irresistible impulse to kill or commit some other offense. The Supreme Court of Connecticut, speaking through Mr. Justice Carpenter, held that a derangement of the moral faculties is in itself a particular form of insanity, which is divided into two kinds, general and partial ; the former consisting in a general exaltation, perversion, or derangement •of function of all the affective or moi-al powers ; the latter of particular morbid impulses, such as kleptomania, or propensity to steal ; pyromania, or propensity to destroj' by fire; and homicidal mania. [Andersen vs. State, 43 Conn. 514.) So also the Supreme Court of Kentucky : " The common law progresses with all other science with wdiich it is affiliated as a gTowing and consistent whole. And, consequently, as the science •of man's moral nature has developed the phenomena of insane affections, 254 ^ SYSTEM OF LEGAL MEDICINE. emotions, and passions, which either nentralize or subjugate the will^ medical jurisprudence recognizes this morbid and overwhelming influ- ence as moral insanity, and pronounces it as exculpatory as the other form called intellectual insanity. No enlightened jurist now doubts the existence of such a type of moral, contradistinguished from intellectual, insanity, as homicidal mania, or morbid and uncontrollable appetite for man-killing, and pyromania, or the like passion for house-burning, and kleptomania, or an irresistible inclination to steal. In each of these cases and others of a kindred character, whether the unnatural passion be congenital or only the offspring of some supereminent cause, moral unhingement and a subjugated and subsidized will are the invariable characteristics. This is disease, and the man thus doomed to the anarchy of morbid and ungovernable passions is, in law as well as in fact, iusane ; and to the extent of the operation of that blind and brutal influence he may be no more responsible than a tiger or other brute." {Smith vs. CommomveaUh, 1 Duv. [Ky.] 224.) The reproach of Lord Chief-Justice Cockburn can with sufficient rea- son be addressed to courts which would affirm, as matter of law, that which it is not the province of law either to affirm or deny, especially when doctrines most dangerous have been laid down dogmatically in the name of advanced science. Tlie fact of the existence of moral and emo- tional mania, of the diseased impulses as types of insanity distinct and apart from any accompanying intellectual derangement, are questions of mental pathology, and as such do not come within a consideration of insanity from the legal point of view. In this connection it suffices to affirm that their existence is not an admitted fact of science, but a the- ory, the subject even at the present day of dispute and controversy. ("Moral Insanity — What is It?" by J. Workman, M.D., American Jour- nal of Lmmify, vol. xxxix., p. 334; "Intemperance and Insanity," by Dr. Chipley, American Journal of Insanity, vol. xxiii., p. 1 ; " Report of the Annual Meeting of the Association of Medical Superintendents of American Institutions for the Insane, held on the 16th of May, 1863," American Journal of Insanity, vol. xx., p. 60 ; Translation by Dr. J. Work- man of " Ulterior! Considerationi suU Argomento della Cosi detta Pazzia Morale," by Dr. C. Bonfigli, American Journal of Insanitj/, vol. xxxvi., pp. 224, 476 ; " Kleptomania," by Dr. J. C. Bucknill, Journal of Mental Science, vol. viii., July, 1862 ; Casper's HanJbooh of Forensic Medicine, vol. iv., part vi., chap, ii., sec. 75, 76, 88, 89, 91, 93.) The problem and difficulty presented to medical jurisprudence by the theory of affective or moral 'insanity would not lie in the abstract ques- tion as to its existence, which is one of fact and one for mental science alone to decide, but in the proof of its actual existence when pleaded as a justification in any particular instance. (Stephen's General View of the Criminal Law of England, chap, ii., p. 95.) This was elaborately set forth by Mr. Justice Allen in his charge to the jury in the case of WiUiam Speirs, who was tried at Rome, K Y., in the year 1858, for having will- fully set fire to the State Lunatic Asylum at Utica, the defense being insanity in the special form of a morbid propensity for " fire-raising." " The defense was made to rest mainly upon the ground of moral insan- ity, so caUed, which under that name had but recently found a place in any of the classifications or divisions of insanity. That the moral affec- tions might be, and frequently were, perverted or impaired by the same MILMJL IlEi^rOXSlIULlTY IX CUIMIXAL CASES. 2.").') diseases, or other causes, wliicli affected or impaired the reasoning fac- uUies and the memory, was not doul)ted. But 'moral insanity,' as a distinct manifestation apart from any derangement of the intellectual faculties or any disease affecting the nund, had not been and could not be with safety recognized by the law as exempting its subjects frt>m jiun- ishmcnt for their unlawful acts. Certainly this cmUd not be done until science should be able to do what it has not yet done — describe its cliar- acteristics and manif(\stations, and detine its evidences and the rules by which its existence could be ascertained and known. It should be capa- ble of being distinguished from moral depra\ity. Men of science, for the convenience of investigation and discussion, might snbdi\'ide and classify these subjects as they pleased, and distinguish their divisions by any nomenclature which might be convenient, and no harm could ensue ; but when courts and juries were called upon to ajiply the princi- ples and deductions of science in the process of judicial investigation, it was indispensable that their tests should be such as were capable of being appreciated and judged with some approximation to certainty ; that is, the deductions and conclusions of science which are to control judicial action and be influential in the administration of justice should be the ascertained results and consequences of facts proved, judged, and applied, according to the well-established principles of the particidar sci- ence involved. Some of the witnesses had spoken of a moral mania, of which an individual might be the sul)ject, and by which he might be im- pelled to the commission of crime ; but juries could not, with any safety, regard a maniacal impulse of this description as absohing fi-om the con- sequences of crime, in the absence of any eWdence of a lesion of the intellect and reasoning powers, or of some derangement or disease affect- ing the mind and judgment — and for the best of all reasons, that there could not, in the nature of things, be any satisfactory evidence of any disease or derangement of the functions of the individual which coidd convince a jury that the act was not tlie deliberate and voluntary act of the party, his mind assenting to it. The existence of the impidsive mania could oidy be proved by the commission of the acts which it was sought to excuse, which would be no evidence at all ; and the jury coidd never know, e^-en should it be conceded that such a ' moral mania ' might and did exist, whether in a particidar case the acts were the results of this impulse or the fruits of a wicked and depraved mind. Courts and juries, in the attempt to determine the existence of ' moral mania ' or ii-resistible im})ulse, apart from mental disturbance and derangement, as evidenced by the well-known symptoms of mental disease, as an excuse for crime, would become bewildered and lost in the labyrinth of scien- tific niceties and fanciful theories. But when called upon to consider the subject of insanity, regarded as a derangement of the intellect, a mental disease, or the manifestations of disease affecting the mind, whether the moral powers Avere or were not impaired or perverted, they were not entirely without the means of arriving at a satisfactory conclu- sion with the aid of intelligent and experienced men and the exercise of their good judgment." (" The Case of "\Villiam %^eii"&,^^ American Journal of Insanitji, vol. xv., p. 200.) It is insisted, however, that the difficidty presented to forensic medi- cine does not end with the disproof or refutation of the theory of a purely emotional or moral insanity : that cases occur where the disorders 25G A SYSTIJM OF LEGAL MEDICINE. in the emotional or moral natnre are the predominant symptoms, the intellectnal lesion being- masked or obscure, these sj'mptoms marking the earl,y stage of what will eventually prove to be an undoubted case of intellectual insanity. It is insisted, further, that under these condi- tions a crime nuiy be committed, the product of cerebro-mental disease. (" The Moral Phenomena of Insanity and Eccentricity," by Thomas Mayo, M.D., The Medical and Psychological Critic, vol. i., p. 173 ; BuckniU and Tuke, Psijchological Medicine, p. 258.) Of this, the case of the boy Wil- liam Newton Allnut, tried at the Central Criminal Court for the murder of his gTandfather by poisoning, furnishes us, according- to the medical witnesses in that case, a practical example ; the accused lieing-, in their opinion, in an early stage of insanity, which affected his nioi'al sentiments and interfered with his notions of right and wrong, but which did not then affect his intellect in any marked degree. (Trial of William Newton AUnut, Testimony of Dr. Densbury and Dr. Conolly, Loudon Times, De- cember 16, 1847.) The difficulty thus presented is obvious even to those who have sug- gested it, and some have attempted its solution. " The vicious act or crime is," says Dr. Maudsley, " not in itself proof of insanity ; it must, in order to establish moral insanity, be traced from disease through a proper train of symptoms, just as the acts of a sane man are deduced from his motives, and the evidence of disease Avill be found in the entire history of the case. Wha,t we shall often observe is this, that after some great moral shock, or some severe physical disturbance, in a person who has a distinct hereditary predisposition to insanity, there has been a marked change of character ; he becomes ' much different from the man lie was ' in feelings, temper, habits, and conduct. We observe, in fact, that after a sufficient and well-recognized cause of mental derangement — a combination of predisposing and exciting causes which are daily pro- ducing it — a person exhibits symptoms which are strangely inconsistent with his previous character, but which are consistent with moral insanity. Or it may appear that there has been an attack of paralysis or epilepsy, or a severe fever, and that the change of character and the symptoms of moral alienation have followed one of these physical causes. In all cases, as Dr. Prichard, who was the first to describe the disease, has remarked, there has been an alteration in the temper and habits, in consequence of disease or of a sufficient cause of disease. Perhaps the strongest evidence of the nature of moral insanity as a disease of the brain is furnished by the fact that its symptoms sometimes precede for a time the symptoms of intellectual derangement in a severe case of undoubted insanity, as, for example, a ease of acute mania, or of general paralysis, or of senile dementia. It is interesting, indeed, to notice that at least one of Dr. Prichard's cases, on Avhich he founded his description of the disease, was really a case of general paralysis — a disease not specially recognized in Ms day, but the best known now of all the forms of mental derange- ment. Surely, then, when a person is subject to a sufficient cause of in- sanity, exhibits thereupon a great change of character, and finally passes into acute mania or general paralysis, we cannot fairly be asked to rec- ognize the adequate cause of the disease and the intellectual disorder as disease, and at the same time to deny the character of disease to the in- termediate symptoms." {Fcsponsihili'fj/ in ]\[enfal Pisease, pp. 173, 174.) MENTAL REsroxsiBir.iTY IS ciuminal cases. 257 Aceortlini^' to Dr. Rtiy, if inoriil insaiiily Ix' iileaded in dofen.so, proof of the fact must be found in the antecedents of the prisonei-, tlie manner of committing' the crime, his mental or bodily condition, all the circum- stances, in fact, connected with the act. {''■ An ]i]xamination of the Objec- tions to the Doctrine of 'Moral Insanity,'" by Isaac; Kay, M.D., yi;><('/-/<;'«« JoiirndJ of Insdiiiff/, vol. xviii., p. 112.) Dr. Take, adnuttinn' that no absolute rule can be laid down to diffei'- entiate moral insanity from moral depraA'ity, insists tliat each case nuist be decided in relation to the individual himself, his antecedents, his edu- cation, surrounding's, and social status, the nature of certain acts, and the mode in which they are j^erformed, along with other circumstances fairly raising- the suspicion that they are not under his control. In no other form of insanity is it so necessarj^ to study the individual, his natural character, his organization, and his previous diseases. ("Moral or Emotional Insanity," D. Hack Tuke, Journal of Mental Science, vol. xxxi., p. 174.) Emotional insanity as a defense has generally been presented under the form of the so-called '' mania transitoria," an instantaneous tempo- rary madness which begins ''in the eve of the criminal act and ends when it is consummated." (Depue, J., 8U(te vs. Grave, 5 N. J. L. J. 54.) The acceptance of this theory by jui'ies as an exculpation of the accused may be regarded in certain cases at least as a proof of their sympathy with him, and of their consequent determiuation to acquit. (" The C'ase of People vs. Eratus F. Pierce,-' Anio'icaii Journal of Insaniiij, vol. xxviii., p. 399 ; Cole's Trial, 7 Abb. Pr., N. S., 321.) The utterances of the law on this subject, so replete with difficulty, cannot receive a complete acquiescence on the part of the jurist. An unwillingness to admit that the facts of insanity were to be learned from science and learned opinion, rather than from ordinary evidence, like an ordinary fact (Lord Chancellor Westbury, Debate of March 11, 1862, Hansard's Debates, third series, vol. clxv., p. 1297), has, as an error, its j)arallel in the intrusion made by the law into the domain of mental pathology itself. The writings of the earliest authorities and some of the judicial utterances of later days, by their attempted classifications of mental disease, and dogmatism as to its essential nature and character- istics, have, under the name of the law, perpetuated or given longer life to scientific errors or the imperfect science of the time, as witness the description drawn between madness and lunacy, the imputing to insanity delusion as its essential and necessary characteristic, and the drawing of fixed legal consequences from the fact of delusion itself. It is submitted that with the particular foi'ms of insanity and its essential characteris- tics as a disease the law has nothing Avhatever to do. The effects of the various manias, of epilepsy, the prol)aT)le limit and effect of delusions, the relation of the insane impulses to the human will, the question as to the existence and nature of an insanity purely emotional and moral, are, and must remain, facts of mental pathology to be proved or disproved as facts, and not to be dogmatically affirmed or denied, and to be viewed only in relation to the legal question of responsibility. As to this it may fairly be asked whether the action of the House of Lords in relation to ^IcNaghten's Case has not justificnl the apprehensions of Mr. Justice Maule, in ULsettling rather than settling, the law by the suggestion of 258 ^ STSTEM OF LEGAL MEDLCINE. doubts rather than the solution of them, thus a,ffording matter for bit- terest controversy between the professions of law and medicine, a con- troversy that extends even to the present time. A complete and unas- sailable canon of responsibility is perhaps yet to be formulated, but its establishment cannot lead beyond the threshold of the difficulties of fact that must always confront the human tribunal. APHASIA AND OTHEE AFFECTIONS OF SPEECH. BY CHAKLES K. MILLS, M.D. HISTORY AXD LITERATURE. The medico-legal aspects of aphasia and other affections of speech have not escaped investigation and discussion, but they have received little attention from English and American wiiters, and, compared with the immense literature of the general subject of aphasia, but Httle fi'om writers of other nations. Much of the work published has been in the nature of records, with comments on particular cases which have come before a coiu't or other tribunal ; and in few, if any, of these contributions has any systematic effort been made to classify for medical purposes the now well-recognized forms of aphasia. In papers deahng with the gen- eral phenomena and mechanism of speech, imj)oriant medico-legal points are developed in a casual and incidental manner, as in the wiitiugs of J. Hugldings Jackson,* Charcot,t Lichtheim,| and Ross;§ and to some of these references will be made in the course of tliis article. In the sec- ond edition of Bateman's treatise on aphasia,] | a new chapter on the jurisprudence of aphasia is introduced, in which some original observa- tions are given, and references are made to the work of French and Ger- man authors. Batemanff cites some cases of interest. In 1743, for example, a resi- dent of Miinden, Hanover, applied to the government for permission to make a "v^'ill by signs in favor of his wife, and the court acknowledged the validity of the act. Another aphasie for five years discharged the functions of mayor and municipal councilor, l)y wi'iting his name to nec- essary documents with his left hand. In the same way he also wi-ote a holographic will, which was sustained. These and other cases are refeired to by Legrand du 8aulle. Bateman refers to several cases in which the wills of deaf-mutes were recognized as valid by the court because it was proved that tliey understood the contents of the will, either through gest- ure and pantomime alone, or by these and wi-itten lang-uage combined. He also records the case of a man, sixty-three years old, who was engaged * Huglilings Jackson, Brain, October, 1S78. and Jnly and October, 1879. t Charcot, Le Procf. MaL, 1884. and Medical Pres^ and Circular, London, 1884. t Lichtheim, Brain, Jannary, 1885. § Ross. Jjiltasia, etc., London, 1887; New York, 1890. II Bateman, Aphasia, etc., London, 1890. U Ibid. 259 260 ^ SYSTEM OF LEGAL MEDICINE. to be married and was suddenly seized with right hemiplegia and apha- sia, and wished to make a will in favor of the lady whom he intended to make his wife. The document was wi-itten by one of his medical attend- ants. The testator's mark was made and the will attested by witnesses. He communicated his wishes by making signs for wiiting materials. Hi& wishes were then interpreted by means of signs and written down on a card. He held up his hand, extended his five fingers, and he was asked if he meant " thousand " ; he bowed assent. He then closed his hand and opened it the same way, implying ten ; this operation was repeated until it amounted to thirty, then he dropped his arm down. Testator was then asked whether he wished Miss R. to have £30,000, and he nodded his head. When asked if Miss R. was to have this sum absolutely, he signified dissent ; but on being asked if it was to be hers for life and afterward to revert to his family, he bowed his head. Unfortunately the testator's mark was made in the middle of the card instead of at the bottom or foot, and so did not satisfy the provisions of the statutes relat- ing to wills, and the testament was therefore refused probate. In Dumas's Count of Monte-Cliristo is an interview with a motor aphasic which might have answered as testimony in court in a case in which the question was that of testamentary capacity. The old Bonapartist, Noii'- tier, paralyzed and profoundly aphasic, angered at his son and daughter- in-law, determines to change his will. His son, his granddaughter, and his old servant could undei'stand and communicate with him through an arranged system of signs — by his closing his eyes for " yes," by winking them when he meant " no," and when he had some desire or feeling to express, by looking upward. He signifies his desire for a notary by indicating to his granddaughter, who recites to him all the letters of the alphabet, that he wishes " n " and " o " in succession ; then with a dic- tionary he picks out the word '' notary." Two notaries are brought and read the formal copy of the will, and then test Noirtier by much the same method as Bateman relates was employed in the case above cited. Several sums are named before the aphasic, who signs " no " until the question is asked, '' Do you possess 900,000 francs ? " In answer to this he closes his eyes in assent. He finally succeeds in making a will, of the validity of which the notaries are thoroughlj^ satisfied, although other characters in the story are not equally satisfied with its contents. At the meeting of the British Medical Association, 1889,* Dr. Drys- dale, of London, cited the case of a celebrated civil engineer who had right motor paralysis and aphasia, but who wrote his own checks, copy- ing them from a former signature of his own, and who for many years was a senior partner of the fii-m. His partners, however, did all the work. In this case the gentleman retained enough intelligence to play whist with the cards spread out before him, and left a ■v^^ll which was not contested. Professor Gairdner, at a former meeting of the British Medical Association, had mentioned the case of a Scottish judge affected "with aphasia who had continued in office for some years, and sat on the bench while suffering from a form of this malady. Legi'and du Saullet has extensively discussed the subject of aphasia * New York Medical Becord, September 28, 1889, p. 360. t Legi'and du Haulle, Gazette dcs Hdjritnnx, June and July, 1868 ; and ihid., vol. Iv., 1882. In this series of lectures other references are as follows : Ch. Sazie, Trouhles Intellectuels dans I'Aphasie, Paris, 1879 ; Finance, Etat Mcntalc des Apliasiques : Con- APHASIA AND OTHER AFFECTIONS OF SPEECH. 2G1 and apliasies c'onsidcn'd fi'oiu the modico-lcji'al and other points of view. He holds that when the lesion of aphasia is eonfined exclusively to the third left frontal convolution, intellectual disturbance is slig-lit ; but according: as it has extended to the motor zone, or to the prefrontal region, will })aralysis or disorders of tlie intelligence appear ; also that most aphasics have a certain measure of dementia as well as of paralj^sis, but that the intellectual disorder observed in aphasics is most varialde, sometimes not interferinii' with the important events of life, at others so wrecking- tlie intellectual faculties as to cause mental incapacity ami irre- sponsibility. Among' aphasics impatience and anger are common ; their moods are very changeable ; want of attention is one of their most marked traits ; memor}^ and recollection are less alert, some aphasics exhibiting decided loss of memory. He insists that aphasia is compatible mtli in- telligence, but tliat this is always more or less weakened by the loss of language. If the brain lesions are extended and multiple, pronounced weakening and even abolition of memory nuiy be oliserved. Incoherence of ideas when present is not by any meaiis on a 2)ar with incoherence of language. To lesions of the prefrontal regions he relates the loss of memory and attention, the incoherence, hallucinations, and delirium — probably only a partial truth. He speaks of hallucinations as frecjuent among aphasics, the most common being those of hearing and sight; sometimes these hallucinations are of a character that may lead to crime, or may make the aphasic suspicious of others. He admits three cate- gories of aphasics — those in whom intelligence is intact, but slightly touched ; those in whom it is manifestly changed : and those in whom it is entirely aliolished. A physician called to give an opinion on an apha- sic should give attention to the smallest particulars. He has need also to use all his care and knowledge in scrupulousl}^ re^ie"\^dng every one of the different forms of language emploj-ed by an aphasic. It is always well to make the patient count, to ask his age, to test him with money, etc. Gallard,* in a volume of clinical lectures delivered at La Pitie, has one chapter on aphasia and aphasics discussed from the medico-legal point of view. His conclusions with reference to the interdiction of aphasics are : (1) If the intelligence of the aphasic is completely obliter- ated, or if in preserving his lucidity he cannot manifest it by "vndtteu language, pantomime, or speech, he should be interdicted ; (2) if the in- telligence of the aphasic, not being completely alienated, has not all its l)rightness, and can onl}^ be incompletely manifested, he should be pro- vided with a judicial counsel ; (8) if the aphasic possesses his intelligence, and if he can manifest it sulTficiently, whether by word, by ^^Titing, or by signs, he has no need of judicial protection, and should be free to man- age himself and his affairs. The Parish will case is perhaps the most famous American medico- legal case in which the mental power of an aphasic was the uuiin point at issue. Henry Parish made his first will when fifty-four years of age, sidrriffioiis Mrdico-Lnjalcs, Paris, 1S7S ; Legrand du SaiiUe, Ftmlc Mcdico-Li'gide siir VI)t(cr(lictk»i dcs Aliciics ct siir Ic Coiificil Jiidicidirc, Paris, 1881, p. 212; J. Lefort, "Reiuarqiies siir I'lnterdiction des Aphasiques," BidJvtin dc la Sovietc de Mcdccinc do France. * Gallavd, CJhnqitc Mcdiadc dc La PUic ; analyzed iu Lc Journal do Mcdccinc ct de Cliirurgic Pratiipies, vol. xlviii., pp. 377-380. 262 A SYSTEM OF LEGAL MEDLCINE. and tlie next year liad a slight apoplectic attack, from Avliicli he soon recovered. Seven years after making his will he had another severe apoplexy, "which left him for the rest of his life, about seven j^ears in all, paralyzed in his right limbs and v^ith the power of articulation lost. After this second seizure he also had at intervals epileptic fits. The codicils to his will were contested. The first was made about six weeks and executed about five months after the severe apoplectic attack ; about four years later a second codicil, and about five yea,rs after this a third, were made. The siuTogate admitted the first codicil and excluded the others. The Supreme Court and the Court of Appeals decided against all three. The trial of this case was a notable one and eminent physi- cians were employed on both sides. Dr. Isaac Ray, who was one of the medical experts, testified in opposition to Mr. Parish's testamentary capac- ity, and has contributed a valuable paper on the case.* " The Beven case is another of interest, reported by Dr. C. H. Hughes, t Mr. Beven had been stricken with right hemiplegia and aphasia, probably due to embolism, as he had a cardiac- valvular lesion. He became defend- ant in a suit for the recovery of money on a deed of trust signed by himself with his left hand when he was aphasic, four months after his first apo- plectic seizure, in 1873. Dr. Hughes, three years after the attack, found that he was suffering from incomplete paralysis of motion on the right side and general angesthesia; that he fully understood oral signs, and written ones tardily and imperfectly; that he recognized the doctor's name and wi*ote down his own name and that of his attorney and of the doctor ; tliat he either had or feigned defective vision, and also impaired hearing in the left ear. He had had three paralytic strokes altogether, but had grown steadily better. Dr. Hughes anah'zed the various facts which were brought forward as evidences of his insanity, and decided in favor of his competency. Dr. Hughes % has also written a paper on the medico-legal aspect of cerebral localization and aphasia. This article reviews the varieties of aphasia, with some consideration of the lesions causing them, and also considers to some extent the effect of simple and complicated aphasia on the judging, comparing, expressing, and other faculties of the mind, citing various- authorities in support of his posi- tions. The Fillmore will case, reported by Dr. Landon C. Grray,§ has at- tained considerable celebrity in this country, both because of its in- trinsic interest and of the distinguished position of the parties con- cerned. Mrs. Caroline S. Fillmore, widow of the ex-President of the United States, in 1877, three years after the latter's death, began to show changes in her character, soon becoming coarse, profane, suspicious, and delusional. She was stricken with hemiplegia. She made two wills, the first eighteen months after the changes in her character were first noted, and nine months before the paralysis ; the second will or codicil was made five months before the stroke. She developed a form of aphasia and slio"vsTd not only this speech disturbance, but a combination of symp- toms of general mental impairment. Dr. Gray and others testified that she was insane and incompetent. * Ray, Contributions to Mental Patlioloffij. t Hughes, American Journal of Iiinanilu, vol. xxxv., January, 1879, p. 410. % Hughes, Alienist and Neurologist, vol. i., April aud July, 1880. iJ Gray, Aiiicrictiii Journal of Xciii'olof/n (did rsijchiainj, vol. iii., p. 549. APHASIA AND OTHER AFFECTIONS OF SPEECH. 203 Ray,* ill liis text-hook, as well as in the monograph on the Parish case, has given some .-ittention to the medieal jurisprudence of aphasia, relating several interesting eases. Diller t has also discussed the medieo-legal aspects of aphasia, and gives notes of two cases. One was a retired physicdan, sixty years old, who had a hemiplegic and aphasic attack, after which he conducted a large busi- ness. An effort was made to break his will on the grounds that he had progressively deteriorated mentally and i)hysieally, and that his will Avas made a few months l)efore his death, when he was technically insane and incompetent. A will which had l)een nuide some years before his attack of aphasia, and wlji('h almost tallied with the contested wiU, was sprung in court and caused a hast}' termination of the proceedings. The second was a case of right hemiplegia and almost complete motor iiphasia in a lady of sixty-five years. She comprehended and expressed clearh' enough certain ideas, and just as clearly failed to express certain others. He finally concluded that she was incompetent to enter into <3ivil contracts and in a technical sense insane, but was aljle to delegate to her children power of attorney. He believed tliat she would be able to give intelligent assent to any single business proposition, but that she was incompetent to receive and pay out money constantly, as her busi- ness required. My own experience mth other cases accords with this conclusion. Diller holds in considering the medico-legal problems that may arise in any given case of aphasia that it is only necessarj' to deter- mine, first, whether the person is sane ; second, whether ideas may be con- veyed to him ; and third, whether he can convey his ideas to others. Clark X has recorded a case in which the question was Avliether a hemi- plegic who also suffered with aphasia was competent to execute a will. After his attack he had recovered largely and had gone on with his busi- ness. He holds that it would not do to declare a man incompetent simply because of his aphasia. I\IEDICO-LEGAL QUESTIONS WHICH IMAY ARISE IN CONNECTION WITH APHASICS. It will be seen from this hasty glance at the meager literature of the subject that the medico-legal questions which may arise in connection with the study of apliasics are somewhat immerous, although all are by no means embraced in this review. They include many of those which the insane present for solution, but also others especially belonging to aphasia. At the outset it should be borne in mind that we are not deal- ing with some clearly defined entity called " aphasia." It is not possible to fix upon any general standard of capacity or responsibility for one suffering from an affection simply labeled ''aphasia." Even correctly labeling an individual as insane does not decide as to his riglit to have certain privileges, or his capacity to do or not to do certain acts, as, for example, to have his perscnml liberty or the control of his estate, to get married, or to make a will. In a pi-actical as well as a philosophical .sense, questions of sanity and insanity are relative, and so likewise are * Rfvy, Medical Jurisprudence of Inscniifi/. t Diller, Jour)i(d of Nerrous aud Moifal Disease, J\[ay, 1804, p. 292. t Clai-k. American Journal of lusanitii, vol. xlix., 1 892-93, p. 291. 2G4 ^ SYSTEM OF LEGAL MEDICINE. tliose presented by apliasics. They will depend not only on the form of the disorder, but also npon its degree and special characteristics in a par- ticular case. " The affections of speech met with are very different in degree and kind," says Hughlings Jackson,* "for the simple reason that the exact position of disease of the brain and its gravity differ in different cases ; different amounts of nervous arrangements in different portions are destroyed with different rapidity in different persons. There is, then, no single, well-defined ' entity ' — loss of speech or aphasia — and thus to state the matter for a practical purpose, such a question as, ' Can an aphasic make a will ? ' cannot be answered any more than the question, ' Will a piece of string reach across this room ? ' can be answered. The question should be, ' Can this or that aphasic person make a will ? ' " These medico-legal questions may be either criminal or civil, although they are much more frequently the latter. Legrand du Saulle says truly that it is rare for aphasics to be implicated in major crimes, being to a certain extent saved from them by their habitual infirmity ; but aphasics are much given to impatience and anger, and their moods are uncertain and changeable and occasionally dangerous. They have been charged with thefts, and have been imphcated in other crimes. One remarkable case is referred to by Legrand du Saulle. An aphasic and hemiplegic was charged with killing his wife, and the case had not only this crimi- nal aspect, but later a civil question, that of the disposal of his and of his wife's property, arose. The parties had been married withoiit a con- tract, and had no childi-en, and each had left to the survivor the whole of his or her property. Attempts were made to nulhfy the donation of the wife on account of ingratitude, as shown by the assassination, but against this it was urged that as the man had been pronounced irre- sponsible he could not be an ingrate. In the end, however, the donation was annulled and went to the wife's heirs. Evidently whether or not an aphasic should be exonerated from the consecpiences of a crime is a vital matter, and in some cases the question should be decided on the same principles that would govern the decision in a case of alleged insanity ; but these might not always suffice, and the presence of the aphasia, and its form, might need to be particularly con- sidered in arriving at a correct conclusion. Many aphasics suffer to a greater or less extent from various special forms of mental diseases, the degree of which may be dependent somewhat on the location of the lesion causing the speech disturbance, or on the extent to which the aphasic lesion has extended beyond the speech centers, or, again, it may be en- tirely independent of the aphasia. The lesion which causes aphasia, as is well known, in addition usually jDroduces a certain and it may be a large degree of paralysis, and less frequently also various sensory dis- orders. The greater the accompanying disease, even though it be of a physical type, the more likely it is that the mentality of the patient will suffer, although this statement must be qualified somewhat by the direc- tion which the lesion has taken. M. Sazie tells of an aphasic who had angesthesia of his limbs, and who believed that his legs had been ampu- tated ; and Legrand du Saulle speaks of monomania, melancholia, hypo- chondria, and of impulses to drunkenness, suicide, or even homicide, * Hughlings Jackson, Brain, October, 1878, p. 314. APHASIA AND OTHER AFFECTIOXS OF SPEECH. 205 among apliasies. Every one who lias had much experience with apliasics can recall such cases, but we must remember that these are disorders occurring* among aphasics, not a part of the aphasia. Recognizing the importance of such facts as these, and remembering also that aphasics who are not in any just sense insane are often greatly misunderstood, it follows that the conunittal of an aphasic to an insane asylum may some- times be a serious question for decision, and might eventually lead to a criminal or civil suit. Kussmaul* refers to the fact that the word-deaf, possessing at tLe same time ability to express themselves in words, but misj^lacing and often distorting them, leave the impression that they are crazed ; and he warns the observer to avoid this error, and also the greater one of re- garding the patient as both deaf and demented. He cites several inter- esting cases — one reported by Baillarger, who demonstrated that a woman who had been regarded as both deaf and demented was really neither one nor the other ; and another of a paraphasic patient of Wer- nicke's, at fii"st supposed to be deaf and crazy. xVn interesting case of aphasia compheated with insanity has been reported by Bancroft, t Among the ei^il questions which arise in connection "udth aphasics, perhaps the first in importance is that of testamentary capacity, and such allied questions as their competency to make deeds of trust or convey- ance, to sign 23owers of attorney, promissory notes, due bills or checks, to make contracts, or to manage any business oi'diuarily invohing speak- ing or %\Titing. The marriage of aphasics may have to be considered. According to French law — and the laws of otlier nations are much the same — dementia is the only thing that interdicts marriage. Aphasia is not suffi(;ieut to prevent it. Signs are recognized as available to signify consent ; but it may be necessary to decide as to the true signification of the pantomime and gestm-es employed by the aphasic. The question is, whether the husband or wife at the time of the marriage had a sufficient degree of intelligence to realize the act, and whether it was of his or her own will. An interesting case is given by Legrand du Saulle of an aged aphasic and hemiplegio mdow who, having fallen out with her daughter, contracted a second marriage against the wishes of her family. I once testified before a register of wills regarding a man whom I had seen in consultation several weeks before his death. This man had lived for many years "v^ith a woman who was not his wife, but by whom he had several childi-eu. By many he was supposed to be legally married to the woman. He was stricken with right-sided pai-ah-sis and pai'tial aphasia ; but I found him capable of answering questions and of read- ing a httle consecutively. I saw him twice before his death, and be- tween my two "sasits he was married to the woman with whom he had been living. The granting letters of administration to his wife was re- sisted by some of his relatives, who claimed that undue influence had been used, and also that he was not in a state of mind to know what he was doing when he was married. After hearing the testimony the reg- ister gave letters of administration to the wife and the case was dropped. The question of interdiction may come up for decision when an * Kussmaul, Zicmssen's Cyclop(cclia of Practical Medicine (American edition), vol. xiv., p. 773. t Bancroft, Boston Medical and Surgical Journal, vol. civ., No. 21, Mav 26, ISSl, p. 483. 266 ^ SYSTEM OF LEGAL MEDICIXE. aphasic is alleged to be insane ; and the decision, as in tlie case of the insane not aphasic, may resnlt in the patient going to an insane hos23ital, or simply being put nnder the control of a committee or of a gnardian. Another question may be of the alleged mahugering of deafness or of deaf -mutism by a criminal, a soldier, or an employee wishing to shirk duty ; and still another whether an apparent aphasia is one of the phases of alleged hysteria. Occasionally aphasia, the resnlt of traumatism, may have a decided medico-legal importance, as in litigation, because of injiu'ies resulting in aphasias ; or when the ability of an aphasic, who has been injured with criminal intent, to recognize an alleged assailant is questioned. In varioiis well-known forms of insanity, as paretic dementia, monomania, katatonia, confusional insanity, mania, or melan- cholia, the peculiarities of the speech disorders belonging to the affections may assist in the early or late diagnosis of such cases, and may thus have a bearing upon such legal matters as necessity of restraint, relief from responsibility, or discharge after recovery. It is not possible to establish rules by which the capacity, compe- tency, or resj)onsibility of aphasics can be measui-ed. This, in given cases, is largely a matter for judicial decision and technical interpreta- tion of the law. In aU. civilized countries, and in different States of a countrj^ like oiu' own, the administration of the law with reference to such matters as wills, deeds of trust, civil contracts, restraint in asylums, and particular crimes, whether relating to aphasics or others, is based upon precedents, and upon legislative and other enactments. These may sometimes be at variance with what is just and equitable from a medical point of view. The object of a paper like the present is chiefly to show the methods of gauging the mental status of those affected mth disorders of speech, which mental status, from the medical point of view, would be the criterion of competency and responsibility ; but such studies might lead to a conclusion that a testator in a certain case was competent to make a valid will, although his testament might not be sustained by a court because of a technical violation of a provision of the law. The French law recognizes tlu'ee kinds of wills : that by public act before notaries and witnesses ; the holographic will, or that wi-itten by the testator's own hand unguided by another ; and the secret will {testament mystique). The secret Avill may be written entirely by the hand of the testator, like the holographic wiU, or be wi'itten b}^ another person and only signed by him. It is then given in charge of a notary in presence of a stated number of witnesses, who countersign the envelope, and by whom it is closed and sealed ; and upon this the testator T^^ites, or causes to be 'wiitten, that this is his ^^n\l duly signed by him. Thus, if the writ- ing and signing of the will are illegible or difficult to read, this act acquires the value even of a holographic wiU. (Gallard.) Under even these or similar laws, an apliasic who, medically speak- ing, might be entirely competent to do certain acts, as could be deter- mined by careful medical examination, would not be able to carry out his own recognizable wishes. Even expressive and correct pantomime would not suffice in such a case. Cases of this kind are mentioned by Legrand du Saulle and others. APHASIA AND OTREIi AFFECTIONS OF SPEECH. 267 DEFINITIONS AND TERiKNOLOGY — ^VARIETIES OP APHASIA. It will be necessary to define certain terms and to give a few of the most important facts with reference to the natm'e and mechanism of speech and its disorders, and also regarding- the sites of lesions prodnc- ing aphasias. While it is impossible to make explicit statements with reference to the mental status — or legal statns, which is sometimes a very different matter — of ai)hasics, basing sncli statements npon the loc;i- tion of a lesion in a certain center, zone, or commissure, something can be done in this direction, and at least one object is to show how far capacity and competency may be inflnenced by the site of a lesion which causes an aphasia. Before the term apliasia, which means "loss of speech," was fully grafted upon medical nomenclature, and to some extent since, numerous other terms have been used to describe disorders of speech from cerebral disease. Alalia was employed by Lordat in the same general sense after- ward accorded to aphasia, but it is not now used or it is restricted to the meaning given it by Kussmaul, that is, an entire inabihty to utter artic- ulate sounds, ranking it under the heads of losses and defects of enun- ciation. Aphemia has also been used by Broca and others for cerebral speech disturbances in general. Ross used it to describe the commonest forms of motor aphasia, the loss of the power of communicating thought by articulate words ; but Bastian has suggested that aphemia lie confined in its definition to defects of speech from lesions of those fillers which connect the motor, or, as he would saj^, "kinesthetic" centers of the cere- brum with the nuclei of the bulb. McLane Hamilton has suggested asemasia, which means an inability to communicate by signs or lan- guage ; but it is too late to displace the word " aphasia," which will be used in this paper in its commonly accepted and general sense to indi- cate cerebral loss or defect in both language and signs. Formerly the terms ataxic apliasia and amnesic aphasia were em- ployed almost universally, and these expressions are retained by high authorities. Ataxic aphasia has been used to describe the aphasia of com- mon ty]ie resulting from lesions of Broca's convolution and the immedi- ately adjacent region, on the supposition that the affection of sjieech is an inability or incapacity for the motor coordination of words ; but as it is a matter of dispute whether or not the affection should be regarded as par- alytic, or even sensory, rather than ataxic, it is best not to continue the use of this expression. Amnesia is loss of memory, and amnesic aphasia is the term wliich has been apjiHed to those affections of speech which are the result of lesions on the sensory or receptive side of the brain. Kussmaul defines amnesic aphasia as the incapacity for the recollection of words as acoustic aggregates of sound ; but objections, based upon theoretical considerations, have also been urged to this term. Disregarding for the present differences of opinion of almost equally high authorities, the best practical subdivision of the aphasias is into sensory or receptive, and motor or emissive. Following such authoritii^s as Kussmaul, Charcot, Broadbent, and Ross, under tlie general term sensory aphasia I include those affections of speech which are dependent upon disease located in the receiving jiart of the brain. Sensory aphasia has, therefore, necessarily several varieties, as word-deafness and word- 268 A SYSTEM OF LEGAL MEDICIXE. hlmdness, terms wMch define themselves; and cq^raxia, sometimes called sonl-blinduess, mind-blindness, or objeet-blindness, wliieli is defined hj Knssmanl as an affection in which the memorj^ for the nses of things is lost, as well as the understanding for the signs for which the tilings are ex- pressed. To test for apraxia, as suggested by Starr,* it is onl}^ necessary to present various objects to a person in various ways and notice whether he gives evidences of recognition ; to have him watched by Ms friends, who will be able to tell whether he still chooses his articles of food at the table intelligently ; whether he still knows how to put on his clothes ; to use various toilet articles ; to sew, knit, or embroider if the patient is a lady ; or to admii-e pictures or flowers or perfumes, as before the illness began. Motor aphasia includes the common form of disorder of speech some- times known as Broca's a]3hasia, and in addition agraphia, or loss of the power of writing, when this is due to disease of the graphic centers of tracts in the motor cortex. Other affections may result from the breaking through of the com- missures or lines of connection between the various centers. These give us what are known in general terms &^ paraphasias or conduction aphasias, which may be of as many tj^es as there are eommissiu'es. Sensory and motor centers and commissures may all be affected at the same time, and this gives the total aphasia of some writers, or what is perhaps better called by Ross comMned sensory and motor aphasia, or by others mixed aphasia. Other terms in use are those descriptive of the peculiarities of sym]3tomatology exhibited by the different varieties of aphasia to which reference has been made, as alexia, dyslexia, and paralexia. Some of the s^anptoms thus designated may be produced by either sensory, motor, or conduction disease, or by combinations of these. Alexia is abolition of the power of reading, as agraphia is that of writing ; dyslexia refers to difficulty or fatigue in reading; parcdexia to misuse by transposition or substitution of either syllables or words. An important variety of aphasia from the medico-legal point of view is that known as verhal amnesia or the aphasia of recollection. Those suffering from this disorder may be neither word-deaf nor word-blind, nor be directly disturbed in motor speech, although the affection may be and often is combined with other forms of aphasia. Pure verbal amnesia is inability to recall the name of an object, quality, or event, al- though the conception or idea of it is present in consciousness. This loss of word memory may be abnost or absolutely total, or it may be so slight as to be little more than a species of absent-mindedness. The proper word is not revived in the memory, although the person or thing is absolutely heard or seen, and is recognized. Nouns, and especiallj'' proj^er or general names, are the parts of speech most commonly lost, because they are the last and the least organized in the brain. Many instances of this disorder have been reported by writers. Besides word-deafness and word-blindness, disorders known as psy- chical deafness and psychical hlindness occur from cerebral disease : the word distiu'bances are perhaps best regarded as degrees or varieties of the more comprehensive psychicnl affections. A case of psychical deafness, however, may in addition to word-deafness, or perhaps inde- * Starr, Neiv Tori- Medical Becord, October 27. 1888. APHASIA A XT) OTIIIin AFFIJCTIOXS OF SPEKCII. 2fi9 pendently of it, have lost general auditory memory for ohjeets and for sounds of definite import. In psychical blindness the A-isual memoiy of forms and colors, and of things in general, may be lost, or the power of recognizing by sight the special properties of ol)jects may be impaired or destroyed ; although even such patients may preserve sight of a lower kind, that, for instance, which would enable them to avoid obstacles l)laced in their path, as the psychically deaf may also by lower centers appreciate vibration or noise. Apraxia, already defined as the inability to recognize the use or meaning of objects, it will be seen might l)e the result either of psychic- al blindness or psychical deafness, or of both. Apraxia and verbal amnesia are not necessarily present in the same case. It is conceivable that an individual might be able to name an object the use of which he did not recognize ; and in a common form of verbal amnesia the patient is conscious of the uses and properties of things the names of which it is impossible for him to re\dve in memory. CEREBRAL CENTERS AND TRACTS CONCERNED IN THE SIECHAJSHSM OF SPEECH. Various schemes and diagrams of the centers and tracts of speech, and of their possible lesions, have been suggested, and almost any one of these might answer for the separation of aphasias in a study of them for medico-legal or other practical purposes. Lichtheim * indicates at least seven localities for diagnostically separable lesions, without includ- ing the visual or concept centers, or some of the h^i^othetieal inner com- missures ; and these might be readily increased to ten or more locations. The principal brain centers or areas concerned with the phenomena and mechanism of speech are : (1) audit oiy (center of auditory images) : (2) visual (center of ^^sual images) ; (3) concept ; (4) propositionizing (center of motor images) ; (5) utterance; (6) gi'aphic or writing; (7) in- hibitory (higher prefrontal centers). Of receptive centers I have mentioned only the auditory and visual for the sake of simplicity, although, of course, impressions received by the cerebral centers for touch, taste, and smell, and particularly by those for touch, may sometimes enter into the mechanism of speech. The chief cerebral tracts and commissures concerned "with speech are : (1) the entering auditory tract, which conveys impressions to the autlitory center ; (2) the entering visual tract ; (3) the commissiu-es be- tween the auditory and concept centers; (4) the commissures between the visual and concept centers ; (5) the commissures between the auditory and "sisual centers ; (6) the commissm^es between the concept and pn)p- ositionizing motor center: (7) the direct tract, sometimes used, between the auditory and propositionizing centers, instead of the innervation passing by way of the concept centers ; (8) the short commissure between the propositionizing and utterance centers; (9) the similarly short com- missure between the propositionizing and gi-aphic or wi-iting centers : (10) the dii'cct tract, sometimes used, from the -visual sensory center to the motor graphic or WTitiug center; (11) the tract or tracts connecting the motor cortical centers concerned with speech and wiiting ^vith the <3enters in the bulb and spinal cord. * Licbtheim. lirahi, vol. vii., Janiiarv, 1885. 270 A SYSTEM OF LEGAL MEDICINE. PARTICULAR FORMS OF SPEECH DISORDER PRODUCED BY LOCALIZED LESIONS. Eestricting ourselves to this number and arrangement of cerebral speech centers and pathways, the first cerebral tract involved in spoken and written language would be the entering auditory tract — the path between the primary auditory centers in the bulb and the cortical center for words, which is situated in the posterior thirds of the first and second temporal convolutions. Lichtheim has placed this path in the left tem- poral lobe, and believes that the radiations from both acoustic nerves and nuclei come together in this side of the brain. Word-deafness would be the chief characteristic of a lesion of this entering pathway, as it would be also of a lesion of the auditory center itself, but in the latter case paraphasia and paralexia would be also present, as the patient would be unable to verify the correctness of his spoken words by hearing. The entering tract for vision passes by way of the optic radiations of Gratiolet, which are chiefly in the occipital lobe, from the primary optic centers in the quadrigeminal body and thalamus to the cortical centers for words in the angulo-occipital region. Word-blindness would be caused either by lesion of this entering tract or of the visual center for words. Experience shows that other symptoms, such as mind-blindness and hemianopsia, are often associated with word-blindness, because the tracts and centers concerned with the functions of sight impaired in the latter disorders are closely associated with those which take part in word vision. It is clear that one form of alexia or abolition of the power of reading, and also, of course, one form of impairment or aboli- tion of the ability to write, would be present in cases of word-blindiiess produced by lesions thus situated ; but it must be remembered that the word-bhnd can sometimes write from dictation or spontaneously, largely by the aid of tactile or muscular sense, and that they can also sometimes copy printed or written text which they may not be able to read or un- derstand, probably as they would copy a geometrical or other figure. Recent authorities are generally agreed as to the necessity of some area and mechanism on the sensory or receptive side of the brain, or in- termediate between it and the motor cerebrum, for a higher intellectual process than the mere registration of auditory and visual impressions — for the formation of concepts in contradistinction to percepts which are represented in the true cerebral centers of hearing and sight, for the or- ganization in consciousness of definite ideas and the identifying of these with names. As to the existence of topographically separated centers or regions for this higher process, considerable difference exists. Some ad- vocate a special naming, idea, or concept center. Others do not consider that a center for the elaboration of concepts is localized in any particular spot or area of the brain, but that this process is rather the result of the combined action of the whole sensorial sphere, and that the commissures between the sensory and motor speech centers and this conceptual sphere consist of converging radiations from various parts of the cortex to the receptive and emissive centers. Ross, for instance, holds that on passing from thinking by percepts to thinking by concepts, and from that to thinking by abstracts, there are no new centers introduced, but only ArUASIA AND OTIIKI! AFFECTIONS OF SPEEfJI. 271 coiiiplieation upon eoiiiplicalion of one perceptive center. Broadbent,* on the other hand, believes tliat a certain convohitional area, whi('li might be called the "idea center" or "naming- center/' exists on the sensory or upward side of the nervous system, and conjectures that it is situeted on the under-surface of the temporosplienoidal lobe near its junction with the occipital lobe, as it seems to him that fibei's from all the convcjlutions in which perceptive centers have been placed converge to and end in the gray cortex of this region. Rosenthal, who is cited by Ross, has recorded a case of verbal am- nesia without word-deafness in a patient suffering from general paralysis, which defect of speech was ushered in by an apoplectiform attack, and persisted unchanged for upward of two years. At the autopsy, besides evidence of a chronic leptomeningitis, an old focus of softening was found in the second and third temporosplienoidal convolutions, the tii'st tem- porosplienoidal convolution being quite free from disease. After all, the existence of a special development or organization of the cortex foi' thinking by concepts and for the clo tiling of ideas in names is recognized by authorities like Ross, Bastian, and others, who differ from Broadbent, Charcot, and Kussmaul, and the school of believers in separate concept centers, only in not restricting this organization to an area absolutely set apart. It is neither improbable nor unpliilosoph- ical that a region conveniently intermediate between all recepitive and emissi'^'e centers concerned in the mechanism of S]3eech may constitute a special, but not narrowly limited, area of the cortex, which is the ana- tomical substratum for concepts and the names which they awaken. The chief affections of speech and of thought due to lesion of this nam- ing or concept cortex, whether it is regarded as an isolated area or as a complication of centers and paths spread over the whole sensorial sphere, are varieties of verbal amnesia or the aphasia of recollection, with usu- ally additional symptoms, such as loss of understanding of spoken or written language, or of volitional speech or writing, because of the al- most necessary involvement of commissures to other sensory and motor centers. Various affections of hearing and speech, or of vision and speech, may be due to lesions of the inner commissures between the auditory and visual centers, or between these and the concept centers, and like- wise various degrees of disturbance of thought and speech from lesions of the paths between these concept centers and the motor regions for speech ; and these disorders will partake of the receptive or sensor char- acter on the one hand, or of the emissive or motor character on the other, according as the lesion is respecti^^ely toward the sensory or the motor side of the brain. Isolated word-blindness, according to Lichtheim and other observers, is the result of a break between the visual and auditoiy centers of word representation. Paraphasia and ^paragraphia, or distui-b- ances in speaking and writing shown in the misuse and jumbhug of sounds and Avords, result from interruption in the commissure between the auditory and motor speech centers, or in the are which unites visual, auditory, and motor centers. If we acknowledge the existence of concept areas as practicallj'' dis- tinct centers or regions, or even if we take the view that they exist as * Broadbeut, Brain, vol. i., January, 1SS7. 272 ^ SYSTEM OF LEGAL MEDICLNE. complications or elaborations of the trne auditory and visual and other receptive centers, then lesions of these higher cell clusters, particularly if extensive, might of course give rise to conceptual disorders of speech and thought. Severance of association tracts between the concei3t and the perceptive centers -may, however, often be the cause of different varieties of these psychical disorders, according to the tracts dissevered. To give a simple illustration, one of my patients, who was both object- bhnd and word-blind, could not recognize a piu-se by sight, but on hand- ling it, examining its clasp, etc., she at once named it correctly ; probably the tracts between the visual perceptive and higher visual areas were de- stroyed, as well as the word centers, while the tactual centers and lines of communication from them to the concept region Avere unaffected. Dyslexia is probably most frequently due to a partial break or lesion in the commissm*es between the visual and the motor aphasic centers, although imperfect destruction of the commissm^e between the casual and auditory centers, or between those for word hearing and Broca's convo- lution, might cause some degi-ee of this disorder. Paralexia, like jDara- phasia, may be due to severance of the communications between either the auditory or visual centers and the motor speech regions. The pm-est forms of motor speech defect will, of course, be due to an isolated lesion either of Broca's convolution, which is the propositioniz- ing center of Broadbent, or of the utterance centers at the foot of the central convolutions, or of both together. Such cases, although not very numerous, have been rej)orted ; some which are well known in the litera- ture of aphasia seem to clearly prove that the loss of propositionizing power is present only when the lesion is absolutely limited to Broca's convolution. While it is true that the power of building and rehearsing in the mind a phrase or sentence and the power of uttering it are commonly lost together, still such a combination does not always exist in aphasic cases. Doubtless two processes of this kind, which are so intimately connected and so often jointl}' lost, have their anatomical substrata in closely ad- joining locahties, and one so-called center might be considered, after the manner of Ross, simply as a comph cation or extension of the other; but still the more elaborated area is separated, even if it be only the shortest distance, from the other. Aj^hasia from the destruction of Broca's convolution should give loss of volitional speech and volitional writing, and if the utterance center or utterance portion of the compound center is destroyed also, the power of repeating and of reading aloud should also be lost. Spoken and written words, however, could be understood, and the faculty of copjing retained. The destruction of the short commissures l^etween propositionizing and gi'aphic centers must nearly always take i3lace in lesion of Broca's con- volution and its subcortex, and hence give motor aphasia and agraphia. In a case recorded by the ^Aaiter of orolingual monoplegia in which a focus of strictly yellowish softening was found involving the lower extremities of the central convolutions both on their external and Sylvian surfaces, and a spot one-half inch in diameter about the middle of the internal portion of the island of Reil, utterance was largely abolished, while prop- ositionizing power remained intact. Clearly, in most cases of destruction of the motor speech centers, as the subcortex usually to some extent takes part in such lesions, commis- APHASIA AND OTHER AFFECTIONS OF SPEECH. 273 «iires of some kind must be involved, and lionee varieties of eonnnissnral or etniduction apliasia are nearly always l)lended with motor disorders, but tliese are oftiMi recovered from in part or whole. Agraphia, or the loss of power of writing', which may, of course, be of the liighest importance in medico-legal directions, may l)e due to lesions variously sitiuited. I have alread}' spoken of what might be termed the sensory forms of agraphia due to lesions of the visual centers or of the entering visual tracts, but even motor agraphia is of several kinds. The patient, for example, may be unable to write spontaneously, although he can from dictation, and he may at the same time be able to coi)y either written or printed text ; or, again, he may not have the al)ility to wiite either from dictation or by copying. Lesions situated in several places may give rise to motor agraphia ; for instance, in the fii-st place, in the special motor centers concerned with writing. Agraphia may again be dependent upon lesions of the tract uniting the concept "udth the speech and wi'iting centers, and if a direct separate tract exists between the visual and the graphic centers, the power of cop^dng ma}' in such case be retained. As propositionizing is as necessary to volitional writing as to volitional speech, destriiction of the third left frontal mil cause more or less agraphia as well as aphasia. "■ The same result,'' says Gowers, " follows an isolating lesion just beneath the cortical center, and hence the path to the arm center must be by the ' associating fibers ' of the sub- jacent white substance, and not the gray matter of the cortex. Bnt it is conceivable that a subcortical lesion may be so placed as to interrupt the paths to the internal capsule and to the opposite hemisphere, and not that to the arm center. In such a case there would be permanent loss of uttered speech without loss of power of Avriting. Such a condition has .actualty been observed." THE MENTAL' STATUS OF SEXSORT APHASICS. In general terms it is doubtless true that mental capacity and its manifestations are impaii^ed most iu those forms of amnesia or aphasia which are the result of lesions on the sensory side of the brain, that is, in word-deafness, word-bhndness, iu the various forms of apraxia or mind-blindness, and in those combined forms of speech and pantomimic distnrbance ^^-llich are due to lesions of the receptive or impressive mechanism of speech. Words seen or heard fail to rcAdve the ordinarily appropriate ideas in memory. Mind-blindness is uot alwaj's associated with word-blindness, nor psychical deafness with word-deafness, but when such an association is present it would requu*e the closest scrutiny of the particulars of a case of alleged capacity or incapacity to determine the true status of the individual, and the presumption would be rather against than in favor of the preservation of mental power for definite purposes. More commonly than otherwise, word-blindness and word- deafness are present in the same case, and quite often the more serious psychical disorders are also associated. While, however, all this is true, it is not correct that word-deafness or word-blindness, or even mind- l)lindness or psychical deafness, necessarily destroys mental integrity to such an extent as to shut out testamentary capacity, the ability to make con- tracts, to testify as a witness, or to take care of one's person or property. 274 -4 SYSTEM OF LEGAL MEDICINE. I\IENTAL STATUS IN WORD-DEAFNESS. Wliat is the mental status of a case of word-deafness ? With what, voluntary acts would such an affection interfere ? First in importance comes the question of testamentary capacit}^ and similar exercises of men- tal power in assenting or dissenting to legal papers. Gowers says that word-deafness is incompatible with will-making, because it is impossible to know whether the testator really understands what is said to him ; but this is putting the matter too strongly. If he is only word-deaf from lesion of either the entering auditory tracts or of the auditory center, but still pre- serves tuR cerebral visual power, and intact lines of communication be- tween the visual center and the motor areas for speech and writing, a will might be made, or other legal papers might express his real intentions. It ought not to be necessary, in other words, for competency that the per- son should be responsive by every channel of communication. This, as in so many other cases of the kind we are discussing, should be studied on its own merits, and testimony as to how the disputed act was done should be clear and unmistakable. Evidently a completely word-deaf ]3atient could not express either assent or dissent by hearing, and pecul- iar statutes might have some bearing on the capacity of a case of word- deafness ; for instance, if it were required by statute that the testator should be addressed by sj)oken words. If he was capable of assenting or dissenting with certainty by any of the legitimate or legal means of communication, he might be competent. Some word-deaf patients are or become able to communicate in spoken or written language, but if the lesion is complete the interference with all methods of communication will also be nearly complete until new centers are educated and new lines of communication opened, or compensation takes place through the other hemisphere. Complete word-deafness is therefore a serious affection in its direct effects on thought and its expression, and also because of the^ conditions with which it is likely to be complicated. Bastian says that a totally word-deaf patient might perhaps not understand wiitten lan- guage, but acknowledges that this ability might persist to some extent through the action of the opposite hemisphere. In spite of the serious- ness of word-deafness, it is a mistake to conclude too hastily that the in- dividual is either incompetent or in an}^ technical sense insane. Word-deafness is one of the forms of hearing and speech disturbance from which partial recoveries are often made and total recoveries some- times occm*. In a number of the cases of combined sensory and motor aphasia observed at the Philadelphia Hospital, word-deafness, at an early jDcriod almost complete, rapidly or gradually disappeared, but not always fully. Many of the patients responded to the last with difficulty or slowness to spoken words. In the consideration of the medico-legal as- pects of word-deafness the fact that patients improve or recover should be constantly borne in mind. The most conflicting testimony might be trutlif ull}'- given about the condition and the competency and responsi- bility of an individual, if such testimony were based upon observations made over a period of a few years or even months. The case of the French Professor Lordat, which has become classic in works on aphasia, is interesting in this as in other particulars. After a fever he suddenly lost his jjowers of speech, and was word-deaf — words AVIIASIA AND OTUEU AFFECTIONS OF SPEECII. 275 ■fell unrecog'iiizod upon liis ear ; but after many weeks he reeovei-ed, i-c- sumed liiw professional work, and wrote a valual)le analysis of his own case. Sehniidt's ease, (pioted by Kussniaul, is interesting- as sh(j\ving the charaeteristie synij)tonis in a word-deaf ease, and also illustrates the fact tliat word-deafness and hig'li grades of verbal annn'sia may in large part disappear. Recovery took place slowly. She did not understand short sentences until after a lapse of half a year, and then oidy when they were pi'onounced slowly and distinctly. Even to the last there re- mained some difficulty in speaking. A word-deaf patient migiit be able to write a will understandingly ; he might retain or soon acquire sufficient powers in speaking to give as- sent or dissent, or even to express an opinion ; he might retain certain powers of pantomime, visual centers and connecting- tracts remaining undiseased and pervious, and the motor areas for pantomimic speech not being- destroyed. It must not be supposed that his condition would be as high mentally as that of a patient deaf and dumb from peripheral disease, as scarlet fever, who had with the aid of vision trained himself in the use and comprehension of sign language. Although secondary atrophj' of hearing or speech centers occm-s in cases of peripheral deaf- ness, a disturbance of mental equilibrium occui-s, and to some extent persists, in cases of cerebral deafness which is not present in the ordi- nary deaf and dinnb. Cerebral centers and lines of communication are at first untouched in the latter cases, and the visual and manual training which is pursued takes possession of and utilizes everything possible. Lichtheim records a valuable case of word-deafness from lesion of the cerebral auditory tract, a rare form of recorded lesion. This patient, al- though word-deaf, differed in striking particulars from a case of word- deafness or speech-deafness from lesion of the center for auditory images. While, for example, he could not understand spoken language, had lost the faculty of repeating, and that of writing from dictation, he preserved intact volitional speech and writing, the understanding of writing, the ability to copy words, and finally the faculty of reading aloud properly, these last being lost in cases of auditory-center deafness. He had neither paraphasia nor paragraphia, because the arc uniting auditory, concept, and motor centers was unbroken. This man's available mental power was greater than that of an ordinary ease of word-deafness. He was, in fact, a teacher and a journalist, and continued with success the business of writing articles for the newspapers. He could understand noises and other sounds of definite import, but not speech. He spoke with absolute accuracy, but with a slight drawl ; he could find substantives, even com- plex ones, and proper names. He copied an I O U wi-itten by Lichtheim, and gave it to his wife, remarking, " You see, you have money." MENTAL STATUS IN WORD-BLINDNESS. A variety of curious problems may be presented by patients suffering from pure word-blindness, or from this and some of its usual complica- tions, as word-deafness, psychical blindness or deafness, verbal amnesia, or paralexia. I have already stated, for instance, that the word-blind can sometimes write spontaneously or from dictation, or even copy writing which they do not undei'stand. Such matters as the simple 276 -^ SYSTEM OF LEGAL MEDICINE. signing of a name to a clieck, to a will, or other document, are often, points in dispute, and yet the ability to do this is retained in many eases where the patient is not only word-blind, but so completely so as to be able to -wTite nothing but his autograph. Letters may be understood when words are not. The understanding for figiu'cs may be lost or re- tained. A patient reported by Broadbent — a case which, after a time, fell into my own hands — could not at first tell how many two and two made, but in two weeks learned to add together two low figures, and rapidly thereafter gained in his understanding of figures. Trousseau has recorded the case of an accountant who could read off the sum 766 fig-ure for figure, but did not know what the figm-e 7 meant before the two 6's. Proust, cited by Kussmaul, records another aphasic who, al- though he could no longer count in words, could add and subtract on paj)er, and even multiply pretty well. That an individual is not able either to read or to wi'ite because of word-bhndness should not absolutely invalidate the writing or signing of a will or other document, although such patient is not exactly in the same condition as one who has never been educated to read or write, or has lost sight through extra-cerebral disease. The general mental impairment, the possibility of the existence of hallucinations or delusions, and the distiu'bance of the equilibrium of thought processes, must aU be taken into consideration. Cases of interest in connection with the discussion of word-blind- ness and of agraphia are mentioned by Legrand du SauUe and Bate- man. An aphasic, fifty years old, wished to make a will, and desired to leave an old domestic a remembrance of some importance. He- made the most strenuous efforts to get together words and express on paper his will in the matter, but the words would not form an intelligible sentence, and the wiiting was incorrect and in some places undecipher- able. This defect of coordination of the will and of movement could not be overcome, and he died before he could make the will he so muck desired, to the grief of the testatrix. Boucher tells of a hemiplegic affected with word-amnesia, who Avished to make a wiU and give a certain sum of money to a relative who had taken great care of him. In spite of the most expressive gestures and pantomime he had great difficulty in making himself understood. He succeeded, however, and, the clew found, he was able to carry out his- washes. The proof of testamentary capacity of a word-blind patient, or the vahdity of a written instrmnent alleged to have been prepared by or for him and having his signature, would have to depend largely upon col- lateral evidence. If it could be shown that such a patient had written a short contract, wiU, or other document, and then had had it read to him, and had signified his assent to its contents, and if the evidence was in favor of his general mental stability, his testamentary and general mental capacity should be sustained. If it should be attemjjted to prove that such a patient had read a document in question, and thereby as- sented to it before signature, the evidence Avould be against its validity and his capacity. A word-blind patient recognizing his defect, but not being word-deaf, and in possession of his general mental faculties, might have a will or other legal paper written for him, and then read to him, and signify his assent to its contents by gesture, by his autograph, or APHASIA AM) OTIIEU AFFECTIoyS OF SrEELU. ^217 l)y his nuirk. The i)ossil)ility of deception liaving been practiced up(ju tlie writer or testator in such a case shonkl, of course, be taken into con- sideration and ehniinated. Word-blindness, Hke word-deafness, often improves so as to chang-e the visual receptive jjowers, and possibly the capacity and competency of the patient. Tlie following (uisc^ will serve to illustrate some of the points likely to arise in the settlement of problems associated with conditions of word- blindness and verbal amnesia. The patient was a married woman sixty- six years old, who had had an attack of hemiparesis. Examination showed that she had right lateral hemianopsia without Wernicke's pupil- lary inaction. Testing- her in a variety of ways it was found that she could recognize objects seen, heard, felt, smelled, or tasted. Until a short time before examination she had been al)le to recognize persons on the street, altliough she could not name them ; but this power of rec- ognition of persons was leaving her. She understood what was said to her. She had four sous, and evidently could tell one from the other^ but could not correctly name them, just as likely as not calling one by another's name. She understood what was read to her, but could not read, as she did not understand printed or written words. She coidd sign her name aud write a few short "words at dictation, although the writing, except her name, was so imperfect as to be almost illegible, ex- cept in the case of a small word like " cat." She could recognize an ob- ject by sight, hearing, or touch ; she could not name it correctly from seeing it, but could do so from touch ; or after it was told to her she would indicate that she knew the name but could not recall it. She called a stamp held before her a " ticket " or a " letter," and said she knew what it was but could not name it. She called pills " pencils," but knew what they were used for although she named them wrongly. When a paste-bottle was held up before her she named it correctly, but called a postal card a ^' stamp," although she knew what it was. She called a watch a "key," and said it looked like a key. When some keys were held up before her she said they were "locks," aud e\4dently knew their uses. On liolding a pocket-book before her she could not name it, but did this quickly when she took it in her hand. BIENTAL STATUS IN VERBAL AIMNESIA, The medico-legal bearings, civil and criminal, of verbal amnesia, or the aphasia of recollection, open an interesting tield, and one not alto- gether unexplored b}^ writers on disorders and disturbances of speech. It is rarely an isolated symptom. It is frequently associated with aprax- ia in some of its forms, or with word-blindness or word-deafness, or both ; it may, indeed, be combined in the same case with abnost all other aphasic affections. Most commonly, as would be expected, it is combined Avith sensorial aphasias and apraxias. I have already discussed the question of special naming or concept centers, leaning to the views of those who hold to the aggregation of these concept centers into a more or less isolated field or zone, but that this concept field is probably not limited to one spot in the sensorial sphere. When more perfect knowledge of localization is attained, it will probably be found that the concept region of the brain is a comparatively large but connected area^ 278 ^ SYSTEM OF LEGAL MEDICINE. interlacing among various centers for percepts in sucli a way as to make certain portions of it conveniently intermediate anatomically between particular percept centers and the special motor or emissive centers with which they are most intimately correlated. Lesions somewhat variously distributed and extended will, therefore, give rise to forms of amnesia and apraxia ; and strange symptom-pictures, difficult to analyze and to refer to these lesions, will sometimes be presented to the clinician and medical jurist. The loss of the faculty of recalling words must interfere to some ex- tent with the acts of thinking as well as with expression. Kussmaul holds, and doubtless correctly, that amnesic aphasia in its most severe forms must render thought mixed and confused, and, unless the affection be merely a light form of the aphasia of recollection, it is almost always accompanied by a pronounced diminution of intelligence. We should not be satisfied with a generality like this, important as it may be, but should, in studying individual cases, separate the varieties of verbal amnesia and apraxia into classes, based upon a study of the relations of the symptoms presented to the sites and extensions of the lesions on whicli these symptoms are dependent. Those deep disturbances of speech and thought which are dependent upon large lesions destroying and disrupting various percept and concept centers, and the lines of communication between them, must so weaken and confuse the mental powers as to make sanity and responsibility in criminal, and competency in civil, cases often a matter of gravest doubt. Many illustrations of forms of verbal amnesia and its most frequent associations have been recorded in the classical treatises on aphasia, and here and there in journals and text-books, but I will only refer to two or three. Kussmaul cites Bergmann's case, in which nouns had disap- peared from the patient's vocabulary, but he still had command of the verbs. A pair of scissors he called that with which one cuts; the win- dow, that through which one sees, through which the room is illumined, etc. The same author also gives the well-known case reported by Hun of Albany of a farrier who understood what was said to him, but al- though his tongue was freely movable he could not find words and had to make himself understood by signs. If the word was written out for him he was able to spell it, and could pronounce it after a few attempts. When he was able to pronounce a word he was also able to write it. Bateman* records the case of a merchant who seemed to understand everything that was said, but had to a certain extent lost the memory of words, and would call things by their wrong names ; for instance, when the fire was burning particularly brightly he said, '' How bright the poker looks ! " Some one said, " You mean the fire ? " " Yes," he said, " I mean the fire." Lichtheim reports a case of lesion of the paths between both the auditory and the visual centers and the concept sphere, with an interest- ing medico-legal experiment. Such a break should give us, according to his analysis, loss of understanding of spoken and written language, with the preservation of volitional sjieech, which would, however, be para- phasic, and of vohtional writing, which would be similarly paragraphic ; also with retention of the faculty of repeating words, of reading aloud, of * Bateman, Aphasia, etc., p. 169. APllAi>IA AXD OTHER AFl'ECTIOSS OF SFKECIL. 279 writing' from dictation, and of copying' words, with, however, a h)ss of in- telHgenee for what is repeated, read ahjud, or written from dictation. The •(> and con should be carefully sifted. Ray, Bastian. Ferrier. Hamilton. Hughes. Bateman, Kussmaul, and many others have expressed the opinion that aphasia from destruction of the motor speech centers does not of necessity mentally incapacitate the individual, and many cases have been recorded by these and other authors to illusti-ate the retention of mental power hy such patients. Even for motor aphasics, however, general conclusions are not sufficient, as such cases separate themselves into several classes according to the site aiul extent of the brain disease producing them. A sharp distinction must be nuide Avith reference to all aphasics, but par- ticularly those in AA'hich the motor type predominates, betAveen having * Starr, Xcir York Medical necord. October 27, 1SS8. 280 ^ SYSTEM OF LEGAL MEDICINE. mental power and being able to make known this possession to others ^ between the capacity to wish and will certain things and the ability by speech, writing, or pantomime to show the desire and intention. In pure motor aphasia, due either to lesion of Broca's convolution or the utterance centers at the base of the central convolutions, or of both, the patient is usually able to make his wishes and purposes kno^Ti, Usually such aphasia is associated with agraphia, but expressive panto- mime is likely to remain in some degree, so that the patient can often communicate intelligibly with others. The impressive and concept spheres of language are not interfered with, and if any clear means of expression and communication remain, the capacity and competency of such a patient will be scarcely questioned. Cases which illustrate this standpoint are to be found in aU articles and treatises on aphasia, and need not be quoted. Even cases of pure motor aphasia naay be some- times misunderstood, if care is not taken in communicating with them. Bastian* says that in pure agraphia thought is least of aU interfered with, while in pure aphasia it is more or less hampered, because the non- revival of glossokinesthetic impressions seems to interfere somewhat with the free and thorough revival of words in other functionally related word centers, even during the process of silent thought. Motor agraphia is usually associated with aphasia of the motor type, and, like the latter,, is also variously combined with conduction or even conceptual and sensorial affections, and its importance will of course depend largely upon its combinations and complications. Cases of either motor aphasia or agraphia of pure type and unasso- ciated with paralysis are rare. By far the most common association is motor aphasia and agraphia combined with types of conduction aphasia and well-marked hemiplegia. These hemiplegic aphasics easily separate into three classes with reference to the presence and persistence of the aphasia: (1) those in which aphasia, complete or nearly complete at first, in the course of days, weeks, or months totally or almost totally disappears ; (2) those in which aphasia is nearly or quite absolute and remains permanently; (3) those which improve slowly, and largety through a tedious process of training and reeducation. The nervous, wards of the Philadelphia Hospital almost always contain some cases of these different types. When the hemiplegia persists although the aphasia passes away, the- lesions are most probably of the internal capsule, compressing or only partially destroying the fibers for the facial centers. The patients recover their speech because of the escape in large measure both of projection and commissural fibers. The mental integritj^ of patients of this class, after the apoplectic period is always retained, and is, as a rule, soon easy of determination. The ability to write and to express thought by panto- mime is fidly preserved on the non-paralyzed side, and to some extent,, when the paralj^sis is not absolute, the paralyzed Hmbs may be made to- do service in expression. In hemiplegic aphasics, in which the aphasia remains nearly or quitfr absolute and permanent, the determination of the mental status of the crippled individual is often a matter of great difficulty. Generally the lesion is one of large size, involving and destroying both internal and * Bastian, British Medical Journal, vol. ii., 1SS7, p. 934. APHASIA AND (JTIIKll AFFECTWXS OF Hl'EKLll. 281 external capsules, and to a {greater or less extent both striate bodies and tlie insula ; in other words, one which, according to oiu' best lights, disrujjts entirely the internuncial tract for speech and also largely the commissures, both direct and iiulirect, between the sensorial and motor centers or between the latter and the center for concepts. The lesion, moreover, is often so close to the cortex for speech as to destroy the commissures which would otherwise connect the left hemisphere with the right tlirough the callosum. Although motor aphasia and motor paralysis of face and limbs are prominent, the ease is in reality one of badly mixed type, and presents phenomena at first sight as confusing to the investigator as the disturbances of thought and speech are to the suffering patient. It is in such a case particularly that a vast difference exists between the possession of thinking power and the ability to com- municate with others. As a rule writing and pantomime are lost in equal degrees with speech ; but every means should be exhausted and every channel of communication tested. So2ne knowledge of the most frequent methods of combination in the mixed aphasias will be of service in attempts at the solution of the medico-legal problems of speech. Brain lesions, usually vascular, are likely to extend over areas and tracts wliich are associated in function- ing, and have, in accordance vdih. a general law, a more or less common source of blood-supply. Different varieties of psychical bhndness and deafness, partial or complete, may occur together; motor aphasia, agraphia, and amimia, partial or complete, are usually associated with paraphasias ; and frequently partial word-deafness is found in conjunc- tion with one or se^-eral of the varieties of motor defect in exj)ression. Total sensory and motor aphasia is sometimes observed, and is of course accompanied by the completest form of speech, graphic, and pantomimic disorder — complete aphasia, agraphia, and amimia. Close studies of these compound cases Avill doubtless better enable us after a time to separate them into different classes, guided by locahza- tion facts and theories ; to distinguish cases in which either the direct sensorimotor or the concept-motor commissures, or both, or the hemi- spheric commissiu'es, are damaged at the same time that the lesion at- tacks cortical centers and cortico-bulbar tracts. The path from concept to motor, or from auditory to motor, centers is certainlv frequently broken, and probably most frequently near the motor end of the hue. Pure or almost pm-e cases of concept-motor aphasia have been reported in considerable number. PSEUDOBULBAR .VXD BULBAR AFFECTIONS OF SPEECH. The form of iufracortical affection of speech which results fi-om lesion of the tract or tracts connecting the cortical centers with the nuclei of the bulb and spiiuil cord is of considerable importance because of the frequent disturbance either by pressure or destruction of this portion of the cerebrum. In many cases of hemiplegia, aphasia, at first very i)romi- neut and positive, after a time disai)pears in large part or even abuost entirely, the paralysis of the leg aiul arm remaining very pronounced. Some of these eases are to be explained by the fact that the intracerebral facial tracts are only affected by pressure, and in others, even when they 282 ^ SYSTEM OF LEGAL MEDICINE. are more or less destroj^ed, the opposite hemispliere assumes the work of both. The common view is that the bilateral movements which occur during; speech may be innervated from each hemisphere. More or less complete destruction of the fibers which connect the orolingual and other facial areas of the cortex with the nuclei of the various nerves concerned Avith articulation and phonation does sometimes give a disorder of speech, which has been variously described as pseudobidbar paral}- sis, labio-glos- sopharyngeal paralysis of cerebral origin, aphemia, etc., and eases have been reported by KirchofP, Ross, Hobson, Bastian, the writer, and others. Two such cases will be given in the section on pantomime. These patients articulate with difficulty ; paresis or paratysis of the tongue is present ; labials and gutturals and Unguals may all be troublesome to pronounce ; drawing of the face will usually be present ; swallowing may be difficult ; the movements of the jaw may be impaired; a^nd drooling is a frequent sj'^mptom. In such cases interference with speech is sometimes extreme, amounting almost to complete speechlessness. While such a train of symptoms usually accompanies a generalized hemiplegia, it is occasion- ally observed unconnected with paralysis in parts other than the face. This pseudobulbar parah'sis is a more decided and permanent affec- tion when the result of bilateral disease, but a form of it can occur from a deep-seated lesion confined to the left hemisphere. Strictly speaking, Broca's convolution is not du*ectly connected with the basal nuclei, but indirectly it is through the utterance or glosso-labio-pharyngolaryngeal cortical centers, a.nd the larger portion of the fibers which go down from these centers to the bulb pass by way of the left hemisphere, although a partial decussation probably takes place. If a commissure connects the speech or utterance regions of the two hemispheres, it must be compara- tively close to the cortex, and its destruction, as well as of the fascicu- lus to the bulb, would accomit for some of the infracortical speech or articulatory disturbances. According to Lichtheim* we are compelled to assimie that only a short extent of the efferent tract from Broca's centers is so constructed as to give rise, on being injured, to real aphasie disturbances ; and we shall therefore have to look also for the lesion of aphasia without agraphia in the white matter of the hemispheres. Anarthria, or disturbance in articulation, rather than a genuine apha- sia, accompanies pseudobulbar or labio-glossopharyngeal paralysis of cere- bral origin. The most marked examples are due to bilateral lesions or degenerations. Whether unilateral or bilateral, all cerebral centers and commissural channels are undisturbed ; volitional sjjeech, word repetition, and reading aloud are lost or greatly impaired simply because of inter- ruption to speech impulses in the outgoing roadways below the cortex. Mental capacity and competency need not be in the least diminished, as the patient preserves his receptive and conceptive faculties and large powers of communication by means of pantomime and writing unless paralysis of face and limbs accompany the aphasia. In true bulbar paralysis, in which the changes iu articulation are sometimes slight and at others so complete as to almost abolish articu- late speech, mental soundness, if the cases are uncomplicated, is not in any degree impaired, and various methods of expression and communi- * Lichtheim, Brain, January, 1885, pp. 481, 482. ArUAiilA AXD OTUElt AFFIXTJOSS OF SPEECH. 283 cation remain. " As in the course of these degenerative changes one ganglion-eell after another is sh)wly destroyed in the bulbar nuclei," saj's Kussmaul,* "we perceive consonants and vowels successively crumbling away, as it were, from the patient's speech, while his intellectual powers may be perfectly retained." The various but allied forms of speech disturbance which result from insular sclerosis and foeal lesions of other sort in the intracere])ral tracts are not necessarily accompanied with any loss of mental strength or clear- ness, although, as is well known, mental changes are somewhat common in this affection because of its diffuse and destructive character. It is scarcely necessary to refer to the peculiar varieties of speech defect found in this well-known disease, which have been Avell described under a vari- ety of names such as di-awling, sj'llabic, scanning, staccato, and hesitating. SPEECH DISTURBA^^CES ASSOCIATED WITH INSANITY. The study of speech disturbances which are associated with various forms of insanity would need an article of considerable length for their full discussion. I can scarcely more than refer to them. As has been said by Dr. Hughes, aphasia dissociated from marked mental impaii-ment is of more frequent occurrence than in association with evident insanity ; so that in a case of suspected mental disease the burden of proof will fall on those who might maintain the coexistence of mental aberration, and the legal presumption would be in such a case in favor of sanity. While this is true it must not be lost sight of that aphasia is found among those who are clearly insane. Broca's first two cases were observed in an institution devoted to the treatment of mental disease, and not a fcAv of the recorded cases have been observed in hospitals for the insane. Every physician in charge of an institution of this character should carefully inquire into the history and symptomatology of cases showing special forms of speech disturbance. The two cases referred to by Kuss- maul will be remembered — patients suffering from aphasia, but not in- sane, and yet confined in an asylum. Probably in paretic dementia and senile dementia the study of speech defects has more diagnostic and medico-legal value than in any other of the well-recognized types of insanity. In the early stages of the former disease it may serve to make clear the true nature of the case ; in the latter affection it may be of decisive importance in the determination of questions of competency. In mania, melancholia, paranoea, katatonia, idiocy, and imbecility the peculiarities of speech might have some bear- ings upon medico-legal problems in connection with the diagnosis of the nature, depth, or stage of the affection. About the hallucinations and delusions of aphasics much of interest might be written. The hallucinations are usually of hearing and sight, and may in not a few cases be dependent upon irritation of sensory cen- ters ; while various delusional states may have their origin in disease of both sensory and concept centers, or in the disruption of various lines of communication between the different areas of the brain concerned with speech. A consideration might be here in place of the inhibitory speech cen- * Kussmaul, oj). cit., p. 65-i. 284 ^ SYSTEM OF LEGAL MEDICIXL. ters, or centers for abstract tliinking, wliicli I have inelnded in the list of centers taking part in the phenomena of sj^eeeh, bnt ■u'hich are not nsnally so included. The_v are probably located in the prefrontal region. Hnghlings Jackson,* Mercier, and others hold that anterior to the Rolandic motor region are the highest motor centers, and that these "with corresponding sensory centers make np the highest level of the central nervous system. Jackson contends that these higher centers represent all parts of the body ; and Mercier that the highest nerve processes which form the substrata of the most elal)orate mental operations represent at the same time not only the most elaborate forms of conduct and mus- cular movements, but also every part of the organism to some degree. Accepting such doctrines, speech, like every other function of the body, must, of coiu'se, be influenced by anything which aifeets these highest centers. Affections of speech due to lesions of these prefrontal areas are a part of the general mental impairment which goes ^vith the destruction of this region ; and the mental status of the individual will be recognized as much by other phenomena as by those of speech. APHASIA AND EPILEPSY. The association of aphasia with epilepsy, and the occurrence of what might be termed an ei3ileptic or epileptiform aphasia "^dthout spasm — or at least without the usual type of convulsion with imconsciousness — may have important medico-legal bearings. Distiu-bances of speech in connec- tion with epileptic attacks are, of coui'se, very common, and may occur before or after or even dming a fit, when loss of consciousness is not profound. Sometimes a seizure is preceded by muttering or confusion of speech, by " thickness of tong-ue," by utterance of certain expressions, by an unusual talkativeness, or by an absolute ina.bihty to talk. The aura of the attack may be a sj)eech disorder. It is not worth while to go into details as to the numerous perversions of speech and thought which so evidently follow epileptic attacks ; they are simply the e^ddences of exhaustion of the cerebral mechanism ^vhich has resulted from a ter- rible explosion of nervous energ}^ Avhieh had occurred during the fit. In addition to these affections of speech, however, are others of rarer occur- rence and of special interest. In some of these the aphasia itself is the fit, just as we may have instead of a motor paroxysm, which is the usual epileptic manifestation, a substitutional attack of mania, of vertigo, of pain, of running, or other automatism. The presence or absence of speech disturbances ^-ith conscious epilep- tic automatism — wliich is perhaps a somewhat contradictory expression — may have some medico-legal importance. Stevens and Hughes t have reported such a case, and many more as similar are to be found in books and journals. This patient, a i^hysician, on several occasions got up in the night, dressed himself, and went out-of-doors to look at his stock, or perhaps simply mthout any purpose. During part of the time at least lie realized that lie was doing something which he should not. He had had many real epileptic seizures preceding these attacks. He was put * Huglilings Jackson, Xew Yorl: Medical Eecorch vol. xxxvi.. Aiigust 31, 1889, pp. 227, 228. t Stevens and Hughes, Alienist and Neurologist, April, 1880. APHASIA AND OTJIEIt AFFECTIONS OF SFEKCII. Ov^-; under treatment and greatly improved, but on another occasion in a similar seizure he was asked a question which he understood perfectly l)ut eouhl not answer, althoug'h he continued to talk for ahout twenty minutes attem})ting to explain what he was trying' to say. The night following' this incident he had a severe ej)ileptic attaitk. He afterward could recall mucdi of what he had said and done when in this confused automatic state. The reporters of the case ask what would have been the result had some acts been done by this patient during his apparently conscious sommxmbulism, something, for instance, involving him in pecuniary obligation, as the signing of a deed, or the doing of any act making him liable to the law. Every ueiu-ologist of experience has seen similar cases, SIJIULATED, JIDIETIC, AND MISCELLANEOUS AFFECTIONS OF SPEECH. The nature of some cases of sudden loss or abrupt disturbance of speech is sometimes obscure and needs careful investigation. The affec- tion might be absolutely assumed or malingered, as, for instance, where it is part of a scheme for dissimulation of insanity, or where it is shammed to present a more serious picture in a litigation case ; or such loss or disturbance of speech might be neuromimetic or hysterical but not absolutely simulated. Many years ago I was sent for in haste to see a young woman who had suddenly become perfectly speechless, causing great consternation to her lover and the other residents of the house. No facial or limb paralysis could be made out, and she had none of the usually associated j)henomena of either an apoplectic or an epileptic attack. This abrui)t loss of speech had come on aftei- a quarrel with her lover, in which both he and she had exhibited violent rage, although no physical force had been used. This case was j^robably one of hysterical aphasia, the result of nervous excitement attendant upon the quarrel. The patient recov- ered as abruptly as she had been attacked. A form of mutism is, as is well known, quite common as a phase of hysteria, but the cases here referred to are those in which the loss of speech comes on as a sudden •attack. The simulation of dumbness by criminals or others should not be over- looked, as it is in fact a simulation of aphasia or in some cases of both aphonia and aphasia. It may be resorted to by criminals feigning to be insane in order to escape the consequences of theii* crimes, or bj'' prison- ers to avoid duties and punishments. Hay* mentions the case of a man who had cut off his wife's head and had or assumed the demeanor of an imbecile. Among other manifestations he carried a piece of wood alxmt with him, which he represented by signs to be a swoi-d. He would not speak or answer any questions except by now and then repeating the word "cabbage" without any meaning. Another French homicide, who was adjudicated insane, would not answer questions, although he heard and understood them. Jean Gerard murdered a woman at Lj^ons in 1829, and immediately after his arrest ceased to speak altogether and appeared to be in a state of fatuity. The use of the actual cautery for several days brought him to terms, and after some urging he spoke, * Kay, ]\Icilical JurisprudcHCc of lusanilij. 286 ^ systi:m of legal medicine. declaring his innocence of the crime with which he was charged. An Itahan criminal became insane soon after he had been betrayed by his- accompUces, and to any question whatever he merely uttered the words ''priest, book, crown, crncifix." Many details are connected with this case, but it was finally decided that he was insane. It is not impossible that he may have been insane and also simulated some of his symptoms. In suspected shamming of dumbness or of aphasia the genuineness of the phenomena should be patiently tested from the standpoint that the defect of speech might be due to the mental state, that is, an aphasia or dysphasia, and also from the standpoint that it might be primary, that is, a true aphasia or dysphasia. The tests for the determination of the presence of insanity or its simulation should be applied as far as possible, resorting to surprises, strategy, and perhaps even in some cases to anesthesia or to stern methods. The apparent aphasia or apraxia should also be tested and studied as is any ordinary case of this alfec- tiou in the sane. Word-deafness, word-blindness, alexia, dyslexia, motor aphasia, and agraphia should, if possible, be investigated and included or excluded ; and the existence or non-existence of accompanpng paralysis^ anaesthesia, hemianopsia, etc., should be given full weight. The disease known as ecliolalia or coprolalia, and by -various other names, might have some medico-legal importance. This is an affection in which convulsive or choreic movements are associated with a sudden explosion of speech. The patient, with a grimace, contortion, or violent- movement of some kind, suddenly bursts into an obscene, profane, or absurd expression. This expression may be the echo of something over- heard — hence the name echolalia — or it may be a spontaneous outcry. It is conceivable that such a patient might be arrested for the use of obscene or insulting language in the presence of others, and physicians and jurists should therefore bear in mind that such a disease exists, and- that the impulse to burst forth in this way is sometimes irresistible. It is not simply an hj'sterical affection, controllable and curable, but is a- true monomania, the affection of speech being beyond the patient's voh- tion. One patient of mine, a boy about twelve years of age, would at times without warning, in a street-car or other pubHc places, as well as in private, suddenly give utterance to a filthy expression two or three times, accompanjdng it with a violent movement of the head and shoul- ders and one arm. Another patient, a lady of good education and fine personal appearance, would in the midst of a conversation, or on intro- duction to another, or at any most inopportune time, suddenlj^ with vio- lent gesticulation shout, " Damn it ! Damn it ! " Gilles de la Tourette^ Dana, Seguin, and others have reported numerous cases of this kind, and the affection certainly has a possible medico-legal aspect. The following quotation from Hughes* may serve to cover some points with reference to the medico-legal aspects of affection of speech not otherwise included in the present paper : " The hysterical, the choreic, the cataleptic, the emotional, the hj^er- emic, and reflex forms of speech failure have neither distinct clmical sig- nificance, nor are they likely often to have medico-legal importance sep- arate from the diseases mth which they may be associated. They need not, therefore, be considered here, and we mention them mainly to ex- * Hughes, Alienist and Neurologist, vol. i., No. 3, July, 1880, pp. 315, 316. Al'UASIA AXD OTHER AFFECTIONS OF SI'EECII. 287 elude tlieni, as wo likewise do the speeclilessiiess of iiiglitmare. Marc and others, however, have noted the temporary impairment of the mental faeulties in ehorea, and the defect in the speech power in this disorder is prol)al)ly as much depeiulent on cere1)i-al disorder implicatinj^ the speeeh center along with other portions of the cortex as on disturbances- of the motor area for the oi-gans of articulation. There are circumstances^ too, under which aphasia occurring in the coiu-se of cerebi-al hyi)eremia might have corroborative significance in a question of doubtful sanit3^ "The occasioual aphasia of drunkenness has never been pathologic- ally defined with sutficient distinctness. It is often, no doubt, a sort of iucom})lete and transient glossolabial paralysis, lil^e the other forms of incoordination seen in inebriates, or the peculiar and more permanent defects of speech displayed by general paralytics. This latter form of speech defect, also, need not be considered apart from the graver disease with which it is associated, and which has other characteristic signs. Nor need we note any of the giossoplegias causing speech defect. " The momentary speechlessness sometimes occurring in persons over- come with fright or profound surprise at being the nnwilling or unex- pected witnesses of some horiible tragedy might possibly be considered where an innocent person is indicted as partkeps criminis from the fact of his being present and uttering no protest or cry of alarm ; but in such, cases the proper explanation, I believe, has always been and is still likely to be made and received, so well understood is the fact by the common mind that intense fear may for a time paralyze the power of speech as well as motion." DISORDEES OF PANTOMIME OCCURRING AJMONG APHASICS. In several places in this chapter the subject of pantomime has been referred to incidentally, but it is of such great importance medico-legaUy and it has received so little attention from writers that it has seemed best to consider it in a separate section. Pantomime is the representation of ideas by action and movement ; it is an intellectual act ; according to Hughliugs Jackson it differs from gesticulation as a proj^osition does from an oath, although the tenns gesture and pantomime are frequently used almost interchangeably. Aminiia and paramimia are terms which have a corresponding import, as regards pantomime, to aphasia, paraphasia, paralexia, etc., with refer- ence to speech. We may have a jargon of signs and motions as well as of Avords and of sounds ; we may have a sensory or receptive and a motor or emissive amimia ; sensory amimia is in fact a form of apraxia. Pan- tomimic disorders may be mixed, combined, or associated ; we may have all blendings of them just as we have the ordinary speech disturbances. A study of the losses and disorders of pantominu^ will often be of great assistance to the physician in diagnosis, and in sonu^ medico-legal cases, decision will largely hinge upon the consideration of the presence, absence, or disturl;)ance of intelligent pantomime. Different and conflicting inter- pretations are too often given to p;nit(unime observed among apliasics; every ease of aphasia should be studied for itseK as to pantomime. Loss or impairment of pantomime is in many cases proportionate to the dis- turbance in speech, but the two do not always go hand in hand, and some patients recover pantomimic power more speedily than ordinary 288 ^ SYSTEM OF LEGAL MEDICINE. speecli. If the visual centers or entering visnal tracts are destroyed, the patient will not be able to use sight in the execution of manual or other forms of pantomime in so far as they may be dependent upon vision. Even impairment or destruction of the enteiing auditoiy tracts, or of the centers for auditory images, might impair pantomime which would otherwise be called out in response to sounds and words heard. The most distinctive interference with pantomime will, however, be from destruction of the center for propositionizing and of the tracts connect- ing it with the concept centers on the one side or the centers for move- ments of the Umbs or face on the other, or from the destruction of the concept areas and their commissures. Some of the most interesting cases of aphasia associated with impairment or destruction of pantomimic or gesticulatory speech indicate differences both in the form of the disorder and in the site and extension of the lesion causing them. In an aphasic who nodded affirmatively with the head when she wished to answer in the negative, and used two fingers to express four, and made similar mistakes of pantomime, a cyst was found destroying a groat part of the third left frontal convolution, the entire left island, and the neighboring medullary substance and anterior third of the corpus striatum.* This patient knew that she expressed herself wi'ongiy, and the disorder was therefore not amnesic ; but many amnesic cases have been reported. In nine cases of aphasia or pseudo-aphasia which were investigated "hj me, notable differences and peculiarities in pantomime were presented by the patients. In one case of brachiocrural monoplegia almost complete motor apha- sia with marked preservation of pantomime was present ; in a hemiplegic with convulsions, word-blindness, verbal amnesia, and motor aphasia, there were marked sensorimotor disturbances of pantomime ; in a third case, one of right hemiplegia and nearly complete aphasia chieflj^ of the motor type, the pantomime was varied and uncertain ; a fourth case was one of right hemiplegia with marked contractures, complete aphasia of the mixed type with a single recurring utterance, and almost complete amimia ; a fifth was a case of rigid hemiplegia, paralysis of the face, almost total sensorimotor aphasia, and obstinacy and energetic emotional gesticula- tion. In a sixth case of marked hemiplegia of gradual development, with motor aphasia and anarthria, only a slight degree of loss of pantomime was shown ; while case seven, one of right-sided pseudobulbar paralysis, with anarthria and preservation of writing ability with the left hand, exhibited also full preservation of pantomime. Case eight was an ex- ample of right-sided pseudobulbar paralysis and ophthalmoplegia, with anarthria, marked orolingual paresis, and full preservation of pantomime, but with considerable mental apathy. The ninth and last case recorded was one of double hemiplegia from successive lesions on the right and the left side of the brain, with absolute abolition of speech and panto- mime. The study of pantomime may become an important diagnostic aid in fijxing subcortical lesions, and particularly the position of a subcortical lesion with reference to its distance from the cortex. Some of the cases detailed showed that when the lesion was entirely in the straits between the ganglia, pantomime was either not lost or soon entirely regained. * Peri'oud, cited by Kussmaul in Ziemssen's Cyclopcedia. jrUA6lA AM) OTHER AFFECTIONS OF SPEECH. 289 The speech defect, as has been stated, is of the nature of an anartln-ia or pseiid()l)ull)ar affection, and a diagnostic point is tlie ability of sn<-h patients to throw even into the paralyzed members some volition, as in the two following cases : Eight-sided Pucudohulhar Paralysis — Anmihria — Preservation of Writing Ahilifij with the Left Hand — Preservation of Pantoniime. F. G., aged tljirty-tive years, a salesman, after an attack of the gi-ippe in 1889, on awaking one morning found that he was i)aralyzed in the right leg, arm, and face, and was nearly speechless. He continued in this condition for four months, during which time he was oidy able to say *' _yes." Speech steadily improved after this. He "vvas admitted to the Philadelphia Hospital in September, 1891. His paralysis had remained about the same, but his speech had gTadually improved, and when he w^as admitted to the hospital he could speak as well as usual ; but about three weeks after admission his speech again suddenly became impau'ed, and at the same time he complained that his jaw felt stiff. He talked in a slow, calculating, hesitating manner, as though it was difficidt to articu- late and enunciate the words he knew. A few days later this disorder of speech cleared up somewhat, but shortly afterward became pronounced, and has remained. His condition as to speech, "when examined by me October 28th, was as follows : He understood w^ords spoken or read to him, also printed or written text, and could read aloud, but read as he spoke — in a peculiarly slow, hesitating manner. He had voluntary- speech, but it was impaired in the same manner as his ability to read ; he repeated from dictation more faintly than he read and tallied. He had no paresis in the upper distrilmtion of the facial nerve. He could not draw up the right side of the mouth, and eoiUd not elevate or depress the right lip as w^ell as the left ; the platysma movements of the right side were also impaired. The tongue showed inefficiency and want of rapidity and strength in its movements. When tlunist out it went a little to the left, arching slightly, the convexity of the curve being upward and a httle to the left ; the inner half of the right side of the tongue was arched, while the outer was depressed. The right side of the tong-ue seemed to be somewdiat atrophied, and in consecpience of this the con- tractions of the lingual muscles were imperfect and changed the usual contours of this organ. His voice had a nasal twang. He had a diffi- culty in swallowing liquids, sometimes regurgitating. The tendon and muscle reflexes were exaggerated, and front tap was present. Marked ankle-clonus was elicited when obtained with the leg extended. The tendon and muscle jerks were well marked in the left leg, but no clonus was present. He had no sensory losses or disturbances anywdiere. Before he was paralyzed he wrote ^\\i\\ his right hand ; since his attack he had taught himself to write very well ^^-ith his left hand. His right arm was almost totally paralyzed, but he had some elbow and metacarpal and phalangeal flexion. Paralysis of the lower extrem- ity was very decided, but not as complete as in the upper, and, like that in the upper, it was of the distal rather than of the proximal type. The movements below the knee were totally paralyzed, as was also the sar- torius movement, or if any power was retained in the sartorius it was 290 ^ SYSTEM OF LEGAL MEDICINE. ■ veiy slight. Above tlie knee ]30wer was retained in tlie reverse order from the proximal to the distal jDortion of the thigh, the hip and pelvis movements being mnch better preserved than those at the knee. A stndy was made of the power of pantomime, both with the para- Ij^zed and nnparalyzed limbs. With the latter pantomime was entirely j)reserved for all practical purposes, snch as beckoning, signing away, pointing to attract attention, emphasizing his meaning, etc. He could also use his badly paralyzed arm to a considerable extent for expressi^-e purposes. On asking him to indicate his age with this arm, he did so by striking with the paralyzed hand on his knee seven times, hfting the lim b chiefly with trunk muscles, showing thereby that he meant his fin- gers multipled by seven, -namely, thirtj^-five years. He was capable of transferring an idea into his paralyzed limb and making use of it, al- though very imperfectly, to communicate with others. He could use the paralyzed member just as far as its loss of motor power would permit. Might-sided Pseiidoiulbar Paralysis and OpMJialmoplegia — Anarthria — MarJced OroUngual Paresis — Full Preservation of Pantomime, hit Con- sideraNe Mental Apathy. J. K., aged thirty-five, white, clerk, was admitted to the Philadelphia Hospital in October, 1887. He had a history of sj'philis. Right-sided paralysis with speech disturbances came on suddenly just before admis- sion ; December, 1888, he had a second slight apoplectic attack. He wrinkled his forehead and closed both eyes firmly, but di'ew up the angle of his mouth better to the left than to the right. In attempt- ing to whistle, the left halves of the lips contracted and puckered, but the right half of the upper lip remained perfectly flat. The right upper extremity was strongly contractured at the shoulder and elbow, so that the arm was drawn with gi'eat force to the side, and carried with the hand spread out across the chest. Loss of power and contractures were the greatest from above downward — from shoulder to finger-tips. He had more power over the distal than over the proximal movements. Strong contractm-e was present at the knee and some at the hip, but he had slight use of the quadriceps and some abihty to flex with the muscles of the thigh. Ankle and foot showed no contracture. He had diminished control over the movements of the foot and toes, proT)ably the less power- over abduction and extension. The general conclusion as to the lower extremity was that paralysis was comparatively complete, and nearly equal for proximal and distal portions, but jDrobably greater in the proximal. Knee-jerk was increased on the right, but no ankle-clonus was present. Sensation was unaffected. G. E. de Schweinitz, ophthalmologist to the hospital, reported as fol- lows : vision about one fifth of normal ; pupils unequal — right, non-re- sponsive to light ; left responds to light and shade. Oculomotor palsy of the right side, with limitations of the movements of all the muscles except those supplied by the fourth and sixth pairs ; also slight ptosis ; in the left eye divergent squint and inward limitations ; the excursion of the eye in the other directions was about normal. Oval disks distinctly atrophic. Marked eccentric narrowing of the fields of vision, the tem- poral fields being correspondingly narrower, but no true hemianopsia. ArilJJSIA AM) OTUEli AFFECTIONS OF SVEECU. 21)1 This man's speech trouble was distinctly an anai-thria. He under- stood everything- that was said to him ; he was neither mind-blind nor word-blind. He eould speak voluntarily; evidently rehearsed phrases and sentences j)roi)erly in his mind ; and, indeed, lie formed and uttered words correctly, althoujj^h he sometimes mispronounced them. His de- fect of speech was clearly due to deficiency in plKuiatinw, articulating, and enunciating'. He spoke with closed mouth and feeble movements of the tongue and li})S ; liis speech was low and muffled — it was wanting in force, tone, and emphasis. Pantomime was practically unaffected so far as his left liml)S and his head, face, and trunk were concerned. Marked differences in the disorders of pantomime will be found in •eases of paralysis and of motor and mixed aphasia which are apparently identical, or at least very similar, in character, which identity or close similarity, however, will often be found to be apparent rather than real ; for investigations will show in many cases differences in degree and char- acter of the motor paratysis, sensory symptoms, and aphasia, which are sufficient to separate the pantomimic disorders into classes. The medico-legal investigator, even without any appreciation of the nature, extent, and location of the lesions, would recognize important dif- ferences between these patients — differences both in speech and panto- mime, which make it essential for just decisions to carefully study both. The "yes" and "no" of an apliasic are well known to have very diverse degrees of value. One of these two words may be used to ex- press both assent and dissent, or with its proper meaning ; or to express assent when dissent is meant, or simply as an emotional, inter jectional, or accidental expression. In like manner, tlie usual pantomimic method of expressing assent by the forward nod or bowing of the head, and of indicating dissent by shakes or half -rotations of the head, or any other movements apparently meaning " yes" or " no," will be found in aphasics to have as many interpretations as the articulated " yes " or " no." The certainty and uniformity witli whicli an aphasic expresses even simple assent and dissent by word or gestm-e, when questioned with, ref- -erence to his wishes or with reference to facts, must be taken into full -consideration. Some cases of aphasia, Avhich were certainly not word- deaf, or only partially so, were carefully tested at the Philadeli)liia Hos- pital with reference to their ability to certainly and consistently exhibit assent or dissent to questions relating to matters easy of comprehen- sion. The results were variable, and sometimes contradictory, puzzling, or amusing. One patient, whose only vocabulary was the word " no," evidently used this word to express both assent and dissent, but accom- panied its use with such an appearance of countenance and such gesticu- lation as to make it impossible to decide as to her real intention. Some- times she seemed to instantly and clearly comprehend what was asked, and showed this by her countenance, but oftener her look was one of annoyance, confusion, or impatience, rather than of either assent or dis- sent. Another patient seemed to understand most of what was said to her, particularly at first, but after a few queries she became emotional, •excited, confused, and decidedly impatient of investigation. A third, whose accompanying paralysis was less complete than that of the other two, but whose vocabulary was chiefly confined to the word " no," as- sented or dissented by means of facial expression, nodding her head, and 292 ^ SYSTEM OF LEGAL MEDICINE. pantomime of fail* correctness, and yet on continuing tlie examination frequently made foolish and absurd assents and dissents. A fourth patient possessed expressive gestui-e and pantomime in a much higher degree. She not only understood all that was said to her, but, within the limits of her original capacity, education, and experience, could, so far as her unparatyzed members would permit, express her mean- ing clearly and distinctly by the most significant pantomime. With the instruments which natui'e had left unimpaired she could promptly indi- cate what she wished to conve}^, and yet she was tremendously crippled so far as ordinary speech was concerned, and had as' a most common method of vocal repty a routine, recurring utterance, '' come-on-to-nong.'^ Her pantomime had high propositional value. In studjdng her panto- mimic powers, for instance, I asked her age, and with her unparalj^zed left hand she opened and shut it fourteen times, the movement becom- ing a little slower and more emphatic as she approached the end. She told us in this that she was seventy years old ; and when I said to her, "You mean you are seventy years oldf" she nodded her head "yes" in a most emphatic manner. I asked her how long she had been sick, and with her hand she promptly told me fifteen years. I said to her, " You mean twenty." She shook her head " no," and again opened and shut her hand three times to indicate fifteen. Great care should be taken not to misinterpret the emotional mani- festations of an aphasic. The gestures and appearances of the face indicative of displeasure, anger, obstinacj^, iiTitability, etc., are often strongly suggestive of dissent ; while, on the other hand, those which merely indicate pleasure, amusement, or playfulness may sometimes be mistaken for assent or accord — facts which the last two cases particu- larly illustrate. True amimia is an intellectual disorder just as is true speechlessness. It may be correct to say that emotional language is apparently unaffected in aphasics, but it would not be correct to say that it is entii'ely unaf- fected. The expression of the emotions, while frequently correct, some- times energetic, and often violent, is in serious cases of distiu'bauce of intellectual pantomime not uniform and under control. In many nor- mal individuals emotional manifestations maj be instantly controlled at an}^ stage ; and, in accordance with varying inhibitor}^ ]30wers in differ- ent individuals, weeping can be turned to laughing, a smile to a frown, the sounds of lamentation to those of rejoicing, by the trained and skill- ful actor, and in varying degree this power of control is preserved in all normal individuals. In aphasics with serious disturbances of pantomime, the losses, when in the emotional side, are seen in meaningless continua- tions or repetitions, slow transitions, and in undue excitement. The following are the notes in detail of two of the nine cases sum- marized above (p. 30) : Right Hemiplegia — Nearhi Complete Aphasia Chiefly of Motor Type — Varying Conditions of Pantomime. R. E., aged fifty-four, white, has been in the wards and out-wards of the Philadelphia Hosj^ital most of the time for twenty years, having first entered the institution because of an attack of apoplexy which occurred during labor and left her aphasic and paralyzed on the left side. She Al'IlA,'ilA jyi) OTIIEU AITECTIOXS OF SPEECH. 293 soon, liowevi'T, hccaine able to walk. Xiue or ten years after tlie first attack she had a fit, and about three years ago she i)robaV)ly had a sec- ond apopleetie attack or seizure, falling in the <^)nt-wards of the hospital. Since this fall slie had complained of much pain in the right thigh and had not been able to walk. This patient showed a curious confusion both of si)eech and panto- mime. !She apparently imderstood all or almost all that was said to her, but seemed to take in what was said with great slowness. She conveyed the impression of one who required a sharp and strong mental stimulus to whip her cerebral centers into activity. She assented by "yes" and dissented by " no," and of tener than not correctly ; nevertheless her " yes '^ and " no " could not l)y any means be relied on — she evidently used some- times one for the other, and presented a difference from the last patient in never correcting herself, "\^^lile apparently answei'ing propei'ly to some easily understood query, in other cases her assent or dissent by speech was foolish or absurd. When, asked, for example, if her name was Smith she answered '• j^es ;" Bro's^^l '? " Yes ;" Jones '? " Yes," etc. She could not or would not repeat anything from dictation. Her pantomime was much aif ected, and, like her speech, of a confusing variety. Frequently, for instance, she used the forwaixl nod for assent appropriately, and similarly the side wise shake or rotation of the head for " no." Now and then, however, she evidently nodded " yes " when she meant " no " ; and this pantomime, like her speech, was never correct spon- taneously. She never used or could be induced to use lier unparalyzed hand and arm to enforce anything she said. In attempting conversations with her she usually made good use of her face for emotional expression ; smiling when pleased, frowning when angered or displeased, etc. To the little speech and pantomime this patient had, the word '' uni-e- liability " was particularly applicable. EUjM Hemiplen'ia With Marled Contractures — Complete Aphasia of the Mixed Type — A Single Recurring Utterance — Almost Complete Amimia. J. E., aged foi-ty, had had two paralytic attacks. The fii'st had caused moderate loss of power in the arm, leg, and face, greatest in the arm, and so far as could be learned had not left her with any aphasia. A f cav months later, three years before the examiiuition here detailed was made, she had a second and more severe apoplectic seizure, which caused pro- found right-sided paralysis and aphasia. The right lower extremity was entii'ely helpless and showed some permanent flexure at the knee, the toes extended and the foot slightly flexed ; the right upper extremity was also totally paralyzed, the wrist and elbow in a permanent position of slight flexure ; the fingers were extended and somewhat approxunated to and looped around the middle finger. The lines of the face were not so well marked on the right as on the left. The tongue could be protruded and deviated to the right. In voli- tioual movements of the mouth and lips — as in an attempt to display the teeth — the face, or moi-e coi-rectlv the angle of the mouth, was dra^vn to the left. Sensation was apparently unimpaii'ed, but the examination could not be thoroughly made. The right knee-jerk was quite spastic, but no ankle- clonus was elicited. A tap on the right patellar tendon was followed by 294 ^ SYSTEM OF LEGAL MEDICINE, visible and palpable contraction of the C[nadriceps mnscle and tendon, but, probably owing to tlie partial fixation of the knee-joint, the leg was not propelled. At rest the toes of the left foot could be seen in regular, rather fine movement. The hj^eru'ritability of nerve, perhaps also of muscle, was also illustrated in the right upper extremities, "\\1ien the dorsiun of the wi'ist was tapj)ed, a feeble but distinct clonus became ap- parent, and gentle taps on the other tendons or muscles — triceps, deltoid, biceps, etc. — caused contractions. Whether or not tliis woman was word-blind I could not determine without a knowledge of her previous history. She was not word-deaf, at least not complete^ so. She impressed me as one of those aphasic patients who having fu'st been word-deaf, or largeh' thus affected, had graduallj' regained some power of understanding spoken words. She was certainly not psychically bHnd. She could close the eyes, protrude the tong-ue, etc., when these or similar performances were gone through before her ; she could also protrude the tongue on command, close the eyes, and lift up the left hand, but scarcely more than this. Her speech and pantomime might be said to be summed up in her ^' la-la" and laugh, and a much less frequent expression of anger or dis- jjleasm'e, which was usually accompanied b}' a movement of covering her mouth with her hand. The appearance of her face could not be said to be without expression, but like her recurring utterance, it was an appear- ance nearly always the same. It might mean that she was ]3leased, it might signify assent or dissent, it might mean nothing at all. Some- times the " la-la " and the laugh became louder and more emphatic, but that was aU. She never nodded the head in the usual manner for " jq^ " or for ''no." Only two differences could be made out in the study of her case : one, that her usual utterance and gTimace were at times more demonstrative or even more violent than at others ; the other was, as above stated, that she had a look of displeasure accompanied by putting the hand to the mouth. A case of this kind would rank in general terms as one of mixed con- cept-motor aphasia. Using the ordinary terms, her loss of pantomime and her loss of speech were both amnesic and aphasic, the former largely predominating. She seemed to be totally unable to conceive or recall either proj^er words or movements. The lesion was of such a character as to have prohibited any education of her right hemisphere for these purposes. It probably destroyed not only both capsules, but also the internal commissures for speech. The following quotation from Kussmaul is of interest in connection with the report of this and the preceding ease : " A woman was paralyzed on the left haK of her body and aphasic from apoplexy. She still had at her disposition only the following little phrases, which she uttered with interjectional sj^rightHuess : * Oui, par- bleu ' ' ' Tiens ! ' and '■ Vous comprenez ! ' When asked if she wished to eat, she answered, ' Oui, parbleu ! ' ^\'liat was her name ? ' Oui, par- bleu ! ' or also * Tiens ! ' in a mocking, snappish tone. She seemed per- suaded that her answers Avere to the point. She often added, 'Vous comprenez ! ' in a tone in which a person would use it who thinks he has convinced the person speaking \nX\\ him. She often made use of gest- ures, which were as useless and limited as her discourse petered out. Here were amnesic or combined amnesic and ataxic derangements." Al'IIASlA AMJ OTUEli AFl'lCCTIOXS OF iU'EECU. 295 I append notes of an interesting case kindly furnished me by the late Dr. J. A, Jeffries, of Boston : Motor Apluma — Onltj Affirmative and Negative Pantomime — Sometimes Confused Contraction of Visual Fields. The patient, a woman fifty-five j'ears okl, married, first came nnder observation Jidy 7, 1891, with a report that she had been struck dumb. Her liistory, as gathered from her sister, and later from herself, was as follows : On the afternoon of the 4tli of July, while celebratuig with some friends, she tripped on a rocking-chair and fell to the ground. She was not stunned, got up l)y herself, and continued about the room for fif- teen minutes ; then feeling sleepy, she lay down on a bed and went to .sleep for two hours. On waking slu^ rejoined the company and began to speak, l)ut stopped short in the middle of a sentence, unable to say a word. She had no pain, vertigo, or other symptoms. She had never been pregnant. She was a strong, straight, healthy-looking woman with an intelli- gent cast of coiintenance. Examination of heart, lungs, and abdominal •organs was negative. Urine 1017, acid, free from alljumin, sugar, bile, and abnormal sediment. No atheroma. A large black-and-blue spot was present about the left eye, extending into the temple. Her eyes moved freely in all directions, either open or with one covered ; no dip- lopia ; pupils of normal size, resj)onded promptly to the light, to near vision, and on irritation of the skin. No ptosis of the right eye ; the left lid drooped, l)ut was much swollen. No difference between the two sides of the face in mimetic movements or in expression of emotion. Tongue extended straight ; could be moved freely and rapidlj' in every direction, and rested symmetrically in the mouth. Fauces symmetrical ; no difficulty in swallowing. Vocal cords moved well in respiration and in laughing ; sneezed with explosion. No i3aresis of neck or of body or legs. Right arm not so strong as the left, but both were fairly strong and freely moved. Tendon reflexes normal, the same on both sides. There was possibly some blunting of the sense of contact in the right arm and face, but the faintest touch was perceived the same as on the left side. Speech was al)sent. On effort to speak there were a few slight motions ■of the tongue and lips, and at times a slight inarticulate sound. The vowel sounds were more pi'ouounced, a and e l)eing recognizable. Could not repeat or read aloud ; could not write alone from dictation or co})y — in all efforts to do so the hand was very clumsy. She could, however, draw at request a dog, house, man, or the like, much after the style of the old Indian inscriptions. She could not read. She apparently under- stood perfectly, doing as she was directed, laughing at a pun. Her only method of conveying ideas seemed to be by nodding or slinking the head. She used no other form of pantomime. When asked a cpiestion she .iissented or dissented ^vith the head, l)ut fi-equently after a nod would ' the spinal cord mig-ht be temporarily perverted or suspended, causing- l)ains, paralysis, and other symptoms. The theory was that the action of a severe injury or concussion upon the sjdne was analog-ous to that of a blow upon the head: just as the latter injury would produce con- (•ussion and a sus2:)ension of (;ereljral function, so it was thought a l)low up(ni the spine AV'ould cause a functional disorder of the spinal cord. These views were based largel}^ upon histories of cases in which after a severe injury paraplegia ensued, which paraplegia in the course of a few weeks or months entii-ely disappeared. Cases illustrating this view were reported l)y Boyer (2),* Bell (o), Sir Astley Cooper (6), Abercrombie (8), Mayo (9), Ollivier (10), and Lidell (11). The earlier writers also studied the effects of injuries in the i)roduction of chronic nervous disorders due to actual iujury to the cord or brain, particularly the former, and cases of traumatic myelitis and traumatic meningitis were put in e^ddence. Maty (1), Clirard (4), and Lidell (11) were among those who contributed to this phase of the subject. In 1818 and 1837 Sir Benjamin Brodie (5) called attention to certain hysterical affections, particularly those of the joints, following injury. We find in the writings of Girard (4), Peronne (12), Weir Mitchell (14), and Lockhart Clarke (15) contributions to the subject of injuries of the nerves and to the development of organic disease of the central nervous system after injury. We find much also in these earlier writers upon the general subjects of concussion and shock. It was not, however, until the appearance of Erichsen's book (13) in 1866 that the study of the functional nervous affections following injury was reall}' begim, and all credit must be paid to this observant surgeon for the epoch-making work which he did at this time. Erichsen's teaching was that injuries would produce at times an actual concussion of the spine, in the sense that it temporarily suspended the functions of that organ and perhaps for some time disturbed its normal workings. He also taught that injuries which did not actually fracture the spine or produce gross lesions of the cord and membranes would lead to various grades of chronic spinal menin- gitis, and finally he taught that following these injuries there sometmies developed peculiar chronic nervous disorders, to which he gave the name '' concussion of the spine," or railway spine. These disorders he consid- ered to be due sometimes to spinal anaemia, sometimes to spinal hyper- £emia, and at other times to meningitis. The authority of Erichsen's teachings remained but little questioned for a good many years. Vari- ous further contril>utions to this subject were made by Buzzard (16), Fletcher (17), Webber (21), and others. In systematic treatises such as those of Erl) (29) and Leyden (26, 31) " spinal concussion" was discussed as though it were a recoguized clinical entity. In 1878 Charcot, reviving the observations of Brodie, called attention to the fact that traumatisms sometimes develop local hvstei'ical i^henom- ena. Esmarch (1872), Shaffer (1880), Ketch (1887), MitcheU (188.")) have also contributed to this same subject. A good many German and a few French wiiters meanwhile reported various cases of concussion of the spine, and most of them accepted more or less fully the views enun- ciated by Erichseu. * The si^eeial ai'tieles by these wi-iters will be found an*anged chronologically imder the bibliography at the end of this article. 300 A SYSTEM OF LEGAL MEDLCLNE. In 1882 a new stimulus was given by Mr. Herbert W. Page, who pub- lished a work entitled Injuries of the Spine and Spinal Cord (51), in which he sharply criticised the views taken by Erichsen. He denied the exist- ence of spinal concussion, and showed that many of the cases of supposed railway S23ine were nothing but cases of a temporary nervous distui-b- ance, or of hysteria or simulation. Shortly before this, Dr. R. M. Hodges (47) had published a series of cases in which he also disputed the seri- ous character of the so-called concussion symptoms. From this time on, the critical study of the traumatic neuroses may be said to have begun. Contributions bearing uj^on it poui'ed in with great rapidit}^ from Ger- man, French, and American observers. In this country Drs. G. L. Wal- ton (55), J. J. Putnam (60), Hamilton (57), Dana (61), Johnson (66), Knapp (117), and Dercum wrote special articles upon the subject. To Drs. Wal- ton and Putnam in particular, credit is due for showing that some of the cases that have been known as railway spine were cases of major hysteria. In France, Charcot (1887) (89) and his puj)ils, Berbez (124), Terrillon (68), and Cuinon (125), studied the phenomena of traumatic hysteria, and showed that, in that country at least, trauma was especially apt to lead to hysterical disorders. In Germany active interest in the subject of the traumatic neuroses may be said to have begun in 1884, when a series of articles was published by Thomsen and Oppenheim, and later by Oppenheim (74) alone. The teaching of Oppenheim was that as a result of injuries there developed a series of chronic nervous symptoms which had a rather definite character, so much so that the special name of " traumatic neurosis " might be ap23lied to it. Oppen- heim's work called out a great many articles of a controversial character, in which it was asserted that the element of malingering had been very much overlooked by the "v^a-iter referred to. It was not until about 1888 that, through the influence of French, American, and English writers, the striking part played by major hysteria was acknowledged to exist in the traumatic nervous disturbances. Dr. William Thorburn (105), in his work entitled A Conirihntion to tlie Surgery of tlie 8pin(d Cord, presented the cpiestion systematically and clearly to English readers. This brings the question down to the present time. It will be seen that at first the whole matter was in the surgeon's hands, and was studied from a surgeon's standiDoint. Erichsen, who first suggested the nervous side of the case, was a surgeon. So also was the first German writer, Rigler. It was not until after the appearance of Page's book that neu- rologists took up the matter seriously. Then clinical and pathological views experienced a rapid change. The conception of a traumatic hys- teria was soon worked out by Charcot, and that of a traumatic neuras- thenia stiU earlier by others. The specific neurosis theory advanced by Oppenheim never secured much of a foothold. The advances being made now are largely in the direction of closer clinical observation and more exact methods of diagnosis, and in pathologj^ and pathological anatomy. Mooted Points. — The points about which present interest most cen- ters are : first, the question of the existence or not of true concussion of the spinal cord ; second, the importance of the part played by malinger- ing in the traumatic neuroses ; third, the existence of a major hysteria with anaesthesias and paralyses ; fourth, the question of the existence of a special class of nervous symptoms following an injury and due entirely THE TRAUMATIC NEUROSES. 301 to it ; fifth, the question of the existence of objeetive signs in these dis- orders l)y which one can test the reality of the alleged nervous phenom- ena; sixth, the existence and significance of local nervous ijhenomena, such as hysterical joints and local hysterical symptoms of a spasmodic or paralytic character. Upon these various points the amount of literature that has accumu- lated is simply enormous. I have ventured to collect this and present it in connection with ni}' article, the matters being arranged fh-st chron- ologically and next in accordance with the different subjects discussed. In the second arrangement I have not included all the articles placed on the first list, because many of them could not be classified and many were simply reports of cases. A study of this bibliographical list shows that the total number of articles and works published is two hundred and seventy-eight. They have appeared from writers in all pai-ts of the ci\'il- ized world. Germany has been most prolific; after this America, then France and Great Britain. English, 27; French, 51; German, 118; American, G4; Italian, 6 ; Scandinavian, 2 ; Swiss, 3 ; Belgian, 2 ; Dutch, 2 ; Russian, 4 : total, 278. It is ob\dously impossible that any one man should familiarize him- self with all these articles ; but I have studied the more important ones, and I am led to the conclusion, from their perusal and from my own personal experience, that many of the mooted questions above refeiTcd to are rapidly reaching a satisfactory solution. Among American neu- rologists of to-daj'' I do not think that there is any great difference of opinion regarding them. As to the first of the points, that of the existence or not of such a thing as concussion of the spine, I beheve that the answer is practically a negative one. It is perhaps not impossible that a severe blow, pro^D- erly directed, may cause a temporary paralysis of the spinal cord due to simply the molecular vibration or concussion ; but such cases are so ex- tremely rare that for practical purposes they need hardly be considered, and personally, despite the cases that have been brought in evidence by Drs. Hunt and Gowers, I do not think that there is any instance which can be said beyond any doubt to illustrate a spinal concussion. Most of the cases that hav^e been called such have been undoubtedly cases of hemor- rhage either external to the dura or internal to it, generally the former. The reader must bear in mind, however, that the term " concussion of the s})ine " is here used in its strictly technical sense. Through the writ- ings of Erichsen and others immediately following him the term was so transposed as to mean not strictly concussion, but the chronic nervous symptoms following it, and often in ordinary medical usage this meaning still oljtains. Few careful waiters, however, now use the term " con- ■cussion of the spine," but in its place employ the words " traumatic neu- rosis," *' traumatic hysteria," *' hystero-traumatism," or some word indi- cating the actual gross lesion if there is any, such as " traumatic myelitis." Sometimes, after an injury, the symptoms of a chronic myelitis slowly develop. This is considered by Knapp a proof that the spinal cord has been "concussed." It rather indicates that some slight laceration of ves- sels or nerve tissues occurs, from which reactive infiammatory changes, gliosis, or most often sj'philitic exudates develop. One sees exact copies of this kind of traumatic myelitis occur without trauma. With regard to the second point, that of the importance of the element 302 A SYSTEM OF LEGAL MEDICINE. of malingering, tliere is perhaps not qnite so mucli liarmony of opinion. This is particularly the case among the German writers, where a great number of articles upon the subject of simulation have been written. There has been, however, in my opinion, a large personal element in this discussion, and a perusal of it leads me to think that most of the Ger- mans who have written regarding simiilation have not been practically familiar with functional neui-oses, such as neiu*asthenia, to anywhere near the extent that American neui'ologists are. It would certainly have been impossible for any such lengthy acrimonious and sterile de- bates as have occiuTcd in Germany to have taken place in America, and in this countiy there is, I feel assiu-ed, no gi^eat difference of oi3inion as to the actual existence and the at times serious nature of the traumatic neui"oses. We recognize, of course, the importance, and I mig'ht add the relative fi'equency, of deceit, exaggeration, and impostiu'e ; also the fact that the jjrocess of litigation often aggravates and adds to the nervous condition. But we do, I beheve, with great uniformity agi-ee upon the fact that functional nervous conditions of a chronic and sometimes in- tractable character are produced by trauma. With regard to the tliird point, that of the existence of a traumatic hysteria, there has been, I believe, no great amount of controversy. It is acknowledged that the major foiins of hysteria as well as the minor fonns may follow ti*auma. The investigations of late years have been more in the line of studying the frequency, the clinical characteristics, and ultimate conrse of these disorders. In France, if we may judge from the medical literatm-e of that country, trauma, when it is followed by any functional nervous disturbance, is followed oftenest by hysteria. In this country traumatic hysteria is relatively rarer, yet it is by no means veiy infi*equent. With regard to the fourth point, that of the existence of a special form of functional neurosis due to injuiy, viz., the traumatic neiu'osis, agi'eement has also been reached. In the vast majority of cases the nervous s^Tuptoms following injury, when not due to organic lesion, take the form of a neurasthenic condition, and this neurasthenic condi- tion diifers Ijut little from that which is l^rought about by other causes. Tramnatic neiu^asthenia s^anptomatologicall}^ resembles ordinary neu- rasthenia plus s}Tnptoms due to local injuiy, such as sprains, and ^-ith the addition of a rather larger amount than usual of pain in the back and tendency to exaggeration. In very rare cases, however, there does develop after a time a chronic nervous disorder, of whose special char- acter I will speak later, which has symptoms that are to a certain extent peculiar to itself, though resembling multiple sclerosis. To this rare t;^-pe of disorder the name of " the grave traumatic neiu'osis " might per- haps be given ; for the e^ddence at the present time goes to show that a certain amount of incurable organic disease exists here. As to the fifth point, the question of the existence of objective signs in the traumatic neuroses, a great deal has been written and a gi-eat deal claimed. Many peculiar symptoms have been elicited and a special s^Tnp- tomatological value attriliuted to them. ]\Iy own ^dews upon their value will be stated in greater detail later. It wOl be sufficient to say now that we have a sufficient number of objective tests to render it impos- sible in almost aH cases for a patient to deceive a skilled observer. As to the sixth point, the existence of local hysterical disorders, there THE rn. I i M. / TIC XK U ROSES. 303 has not yet been very much written, and the subject is in a soni(;\vhat misatisfaetory state. It lias been shown, however, that arthralgias, local spasms, paralyses, and tremors may result from injury, and that these may exist and be of a purely functional character. The (juestion of the amount and importance of asso(dated hysterical or neurasthenic stigmata lias, howex'cr, yet to be woi'ked out. Such, in biief, is the history of the rise and development of our knowledge of the functional nervous disorders following injimes. Classification. — It is hardly to ha expected that perfect agreement can yet lie reached upon the sul)ject of classifying the functional nervous disorders that follow injury and shock. A classification suggested by Dr. E. C. Seguin in 1889 {Annual of the Universal Medical Sciences, vol. iii., No. 3), modified somewhat in accordance with the advances made since that time, will be used as a guide here. CLASSIFICATION OF NERVOUS DISORDERS FOLLOWING INJURY. Immediate Symptoms : f Shock, Transitory paralysis, Delirium, somnolence, amnesia, Diabetes. Late Symptoms, l^liis (in many cases) physical injuries : 1. The Traumatic Neuroses. (ft) Traumatic neurasthenia. {!)) Traumatic hysteria, (c) Mixed and grave types. ((7) Local neuroses. 2. Organic Affections. (rt) Myelitis, meningitis, etc. (Z>) Degenerative diseases of brain and cord : \dz., locomotor ataxia, progressive muscular atro- pliy, miiltiple sclerosis, epilepsy, paralysis agi- taiis, ties, exophthalmic goiter. • (c) Lifeetive neuroses : chorea, sj'philis, tubercu- losis. (r?) Tumors. 3. Psychoses. Out of the above long list I have to discuss only the subjects of shock and the traumatic neuroses. It is these which are most common aside from physical injury, and it is these which give rise to the most important kinds of litigation. It is extremely rare for other forms of nervous troubles than the neuroses referred to to come into court. Chorea, for example, though often excited by fright, rarely occurs in adults, and is almost never developed in connection ^\'ith litigation cases. Epileps}', too, though sometimes the resnlt of injiuy, occurs chiefly before maturity, and it is not often that the disease can be shown to be due to an injury alone. SHOCK AND CONCUSSION. The nature of shock and concussion has already been defined. Con- cussion is the physical jar; shock is the effect. Shock resulting from concussion is called corporeal ; but almost the same class of symp- 304 A SYSTEM OF LEGAL MEDLCINE. toros can be produced l3y great emotion, and tliis form of shock is called psycliical. When a person receives a severe blow upon tlie head he falls to the ground partly or wholly unconscious. His voluntary muscles are re- laxed, and often there is at the same time a paralysis of the sphincters, so that faeces and urine are voided. The pulse is slow, irregular, weak, and comj)ressible. The reflexes are abohshed. The respiration is shal- low and slow in rhythm. The extremities are cold, the face is pale, the skin often covered mth moisture. If the patient dies in this state of collapse, post-mortem examination may reveal a localized blood-clot or a slight amount of laceration of the brain substance under the point of injury or at the opposite i)ole of the brain. In some cases minute hem- orrhages are found throughout the substance of the brain, in other cases no change whatever is found excej^t perhaps a congestion of the vessels of the pia mater. A number of theories have been put forth to explain the profound effects produced by blows which are not associated with any gross lesions of the brain, but which yet produce most serious effects upon the ner- vous centers. The prevalent theory is that of Duret, that the effects are produced mainly through the sudden driving of the cerebro-spinal fluid from the subarachnoid space through the foramen Magendie into the fourth ventricle and thence into the central canal of the spinal cord, and through the acjueduct of Sylvius into the ventricular cavities. The fatal objection to this theory is that, as shown by Kocher and Ferrari, pressure in the intracranial cavity is transmitted in all directions, as in a fluid, so that the pressure in the ventricles can never be any less than that out- side the ventricles. The theory which appears most to satisfy the re- quirements is that which has l3een recently worked out by Mr. Victor Horsley, and which has been described with great clearness by Dr. S. B. Kramer, of Cincinnati.* It is based on a number of experiments in which the blood-pressure curve, the respiratory curve, and the intra- cranial tension were simultaneously registered. It was found that when a sudden severe blow was given uj)on the skull there was an immediate and sudden rise of intracranial tension ; in other words, the sudden blow compressed the elastic skull and squeezed the contents of the brain, pro- ducing an instantaneous and severe compression of the brain. The brain substance, it is true, is only very slightly compressible (Adamkie\\dcz), I)ut, as these experiments show, a slight amount of compression can be made, and the force of the blow produces this effect. The compression exerts its force mainly upon the soft-walled blood-vessels, that is, the capillaries. The blood is driven out into the veins and thence into the extracranial circulation. As a result, therefore, of this sudden compres- sion and rise of intracranial tension there is an extreme thoTigh very brief anaemia of the brain produced. This anaemia affects the parts sup- plied by the capillaries, which are essentially the cortex and ganglia of the brain. There is, therefore, produced in concussion of the brain a sudden intense asphyxiation of the important nerve centers, and as a result of this their functions are suspended. In the process of restora- tion of tlieir functions there is necessarily some disturbance due to the sudden and violent disarrangement of the vascular equilibrium, and this * Cincinnati Lancet Clinic, January 27, 1894. THE TRAUMATIC NEUROSES. .30r> distiirbiince is accompanied pc'rliup.s with dilatation and rupture of small vessels. After concussion there arise sometimes a long train of nervous symptoms, -which I shall describe later. SPECIAL DESCRIPTION OF THE TRAUMATIC NEUROSES, IN- CLUDING TRAUMATIC NEURASTHENIA, MIXED TYPES, TRAUMATIC NEUROSIS OF GRAVE TYPE, ^VND TRAUMATIC HYSTERIA. Tlie effects of concussion and shock having in a measure passed away, the patient sometimes develops some form of chronic functional nervous disorder, to which the general term "traumatic neurosis" is applied; or without concussion, and with only some slight psychic shock and physical injury, similar symptoms may arise. It is tliis class of disorders which I shall now specifically describe. '^Etiology. — While the exciting cause of the traumatic neuroses is alwa3''S trauma, there are many conditions which prepare and ripen the system for a nervous disease, and these causes will be considered first. Age. — The period of life most susceptible to the traumatic neuroses is that between the twentieth and fortieth year ; that is to say, the most active years of our existence. The cases occur oftenest in the decade twenty-one to thirty, next, thirty-one to forty. Practically no cases occur after the sixtieth and very few before tlie twentieth year. Tliis is shown in the following table of cases of traumatic neurasthenia, hys- teria, and hystero-iieurasthenia, compiled from cases reported by Erich- sen, Page, Berbez, Oppenheim, Weill, Knapp, Dercum, Bremer, Clevenger, and myself. Ages. All Cases. American Cases. 10 to 20 7 4 21 to 30 52 25 31 to 40 50 19 41 to 50 40 11 51 to 60 16 4 61 1 1 166 64 The youngest cases were boys aged ten and a half and twelve, who had hystero-neurasthenic troubles from a fall on the head, (Weill.) The average age of the French hysterical cases (Berbez) is twenty-five years, the male cases being the older. The ordinary neiu'asthenic cases are more frequent between the ages of thirty and forty. The fact that people between the ages of twenty and forty travel more and are more exposed to injuries has something to do with the prevalence at this period. Still, the first two decades of life enjoy a great though not abso- lute immunity. In this country the neurasthenic cases occur more fre- quently in the earlier decades. This is a peculiarity which I have noticed of other neuroses, such as megi'im, chorea, and ei)ilepsy. Sex. — Traumatic neuroses occur in men often er than in women, in the proportion of 3 to 1 (144 to 52). Traunnitic neurasthenia occurs relatively oftener in men (2 to 1). This relative excess of the male is due partly perhaps to the greater frequency with Avliich men travel and are exposed 806 -4 SYSTEM OF LEGAL MEDICINE. to accidents ; perhaps also to some extent to tlie great readiness of men to resent injnry and to attempt litigation. Still tlie same excess exists in neurasthenia due to other causes. The German statistics give a much larger percentage of males. Among 33 cases of Oppenheim's only 2 were women. Previous Condition of Health. — There is a very fii-m conviction among most neurologists that a neurotic constitution or some condition of ill-health exists in a large proportion of the genuine cases of traumatic neuroses. This is certainly true for some types of hysteria, and to a less extent, in my experience, in neurasthenia. Those cases which develop degenerative diseases of the central nervous system have in some cases been infected with syphilis, or have been accustomed to excesses in alco- liol and vener}'-, or have been subject to strain and privation. Sexual excess stands in especially important relation with hysteria. I have known slight trauma to bring out an attack of nervous syphilis, and to cause its exacerbation in quiescent cases. I have known also trauma to excite chorea and afterward hysteria in a patient who had Bright's dis- ease. This factor of previous condition of health and personal predis- position to nervous disease ought to be very carefully considered in esti- mating the responsibility of a person or corporation for injury. Rigler thinks that railway officials are predisposed to traumatic neu- roses, on account of the irritation of the nervous centers from the con- tinual vibration. This may be true of locomotive engineers, who espe- cially suffer from concussion, and who are also subject to much mental strain. Statistics show that it is not true of other employees, and there are not enough facts at hand to enable me to speak positively about the engineers. They sometimes develop neurasthenic conditions simply from the nature of their work, just as other people do. Concentration of Population. — Dr. W. B. Outen, chief surgeon of the Missouri Pacific Railroad Company, finds that traumatic neuroses develop much more frequent^ in the neighborhood of populous cities. Thus, among 814 injuries to passengers occurring at points remote from cities, only 6 eases of traumatic neurosis developed, while among 30 passengers injured on suburban trains there were 5 cases of traumatic neurosis. Furthermore, among 18,275 injured employees only 8 were credited with traumatic neuroses, 4 of whom recovered. There were, however, 767 injuries to the back of various kinds. Among injured passengers there was 1 neurosis to 76-1^- ; among employees, 1 in 2248|. The employees were all taken, however, and promptly treated in the- company's hospitals. Dr. Outen's view that many of the cases of neu- rosis were the result of suggestion and litigation is no doubt in a measure true. It may be said, however, that people living in remote districts are not so able to fight for their just rights, and are, as a whole, more ignorant of a corporation's responsibility. Mr. Frank Loomis, attorney for the New York Central and Hudson River Railroad Company, tells me that very few cases of traumatic neuroses occur, in his experience, on that company's lines. Condition at Time of Injury. — There is no doubt that persons who are injured while asleep or intoxicated are less liable to severe neuroses. This is partly due to the fact that the element of fright and psychical shock is, in a measure, eliminated in these cases, and partly to the re- laxed condition of the body, which renders the physical shock less violent. THE TRAUMATIC XEUltOSES. 307 Persons wlio are acoustoiiied to travel, and, like old soldiers, are some- what innred to the po.ssil)ilities of aeeidents, are less likely to be injured than inexperienced trav'elers, who are full of apprehensions at every sug- gestion of dauii'er. Condition Subsequent to Injury. — Persons who are promptly and propei'ly eared for after accidents are less liable to become nervous. The innnediate resumption of severe work and the careless use of stimulants and narcotics no douljt favor the development of nervous symptoms, if such were destined to appear. More than all this, however, is the effect upon the patient of the attentions of lawj^ers and unwise physicians who are trying to make out a case. The worriment of litigation naturally Tjrings out and intensifies many symptoms. On the other hand, many t^'pical cases of traumatic neurosis occur when no litigation exists ; and the attempt to put down even the majority of eases of traumatic neuroses to suggestion and litigation is quite unjustifiable.* The foregoing description of the causes of the traumatic neuroses ap- plies to all forms of the functional nervous troubles. In undertaking to describe the symptoms, however, it is necessarj^ to make certain clinical types, and describe these separately. As I have studied these nem-oses they can be mostly grouj)ed under the head of : 1. Traumatic Neurasthenia. {a) Mixed Types. 2. Traumatic Neurosis of Grate Type. 3. Traumatic Hysteria. Symptoms of Traumatic Neurasthenia (Railway Spine). — The ner- vous symptoms which follow shock and injury, and wliich take the neu- rasthenic type, are not always alike, though they bear a general resem- blance to each other and to neurasthenic states from other causes. The most common series of phenomena is that which may be grouped under the head of a simple traumatic nem-asthenia. Tlie history of a patient is something like the following : After receiving an injury which is often but slight, but which is usually accompanied with a gi-eat deal of fright and emotional disturbance, the patient goes to his home feeling perhaps a little nervous and shaken, but not suffering to any great extent. He goes to bed and sleeps ; wakes up * There are 175,233 miles of railroads in the United States, and in the year 1892, 575,769,678 passengers were carried. One person is killed yearly out of every 3,800,000 passenger trips taken, and there is one death to every 4,600.000 miles traveled in the United States. The frequency of fatal accidents in this country is -^ times gi-eater than that in the United Kingdom. This is due to the fact that our railroads are more clieaply built and more numerous, and that there is proportionately a greater amount of travel upon them. OoUisions are the cause of nearly one half of tlie train accidents, and these accidents are due in ten percent, of cases to road defects and in about fifty percent, of cases to negligence. (H. G. Prout, XortJi Awerivan Ihvh'U- and Poor's M(i»ii(d.) As showing the frequency of accidents in a large city, I have obtained, tlirough the courtesy of the New York City Board of Health, the "statistics as to the mortality rate from accidents due to injuries received on the elevated, street railroads, and other vehicles in tliis city. Deaths caused by street accidents in New York City in the year 1892 : elevaled rail- roads, 8 ; other steam railroads, 5G ; street raihoads, 49 ; other vehicles, 73 : total, 186. 308 A SYSTEM OF LEGAL MEDICINE. the next morning:, feeling not quite as well as nsual, but eongTatulating Mmself, perhaps, on having gotten off so easih^ He resumes his work and finds that he can do it, though with not quite so much ease as usual, and he very likely suffers from some pain due to a strain or bruise- that he has received. In a few days, almost always within a week, he begins to notice that he is more nervous than usual, that Httle things irritate him which did not do so before, that his head seems somewhat confused, and that the effort to work is wearjing. His sleej) is disturbed, and he wakes up in the morning uni'efreshed by his night's repose. He becomes somewhat despondent over his condition, and thoughts of paralysis or some other serious aihuent annoy him. His head aches, the pain being more or less constant and diffused, and located usually over the forehead or at the back of the neck. He has unpleasant sensations in the head, such as that of constriction or pressui'e or scalding feehngs. His back also is continually painful, and walking increases it. His nervousness becomes more marked, and close examination shows a little fine tremor in the hands. He has also sometimes creeping sensations over the body or numb feehngs in the extremities. He tires very easily. He is emo- tional, and becomes more despondent as the days go on. Sometimes he has sj)ots before his eyes, noises in his head, or ringing in the ears. Eeading is laborious and increases his headache ; so also does attention to work. His appetite becomes capricious and his bowels are constipated. He suffers somewhat from flatulency and dyspepsia. His heart palpitates easil}^, and the pulse is a little accelerated. Sometimes for a few days there is a little weakness about the liladder or irritabihty of that discus. His sexual power is diminished ; his cu'culation seems rather poorer than usual. Verj^ sUght excitement produces sweating of the hands or cold- ness of the extremities. He loses a little flesh. These s}Taptoms may be several weeks in developing, and during this time he may perhaps consult a lav^^^er aliout his case. If so, the anxieties of litigation begin to add to and intensify his troubles. He consults a physician, and the physician finds the subjective sATuptoms that I have mentioned. Objectively, when examined, the physician mil discover that the muscular power is somewhat weakened, that there is a certain amount of fine tremor, perhaps in his hands. The knee-jerks and ell)ow- jerks are exaggerated ; there are tender points along the spine and upon the head. On making liim stand with his eyes closed there is a certain amount of static ataxia discovered. The pupils are often dilated and mobile, and examination of the ^dsual field shows sometimes a slight con- traction, at other times the '' shifting t}T3e," to be described later. In many cases a degi^ee of peripheral retinal anaesthesia will be discovered. The pulse will be found accelerated, and pressm-e on a tender point wilL send it up very rapidly ; a slight exertion "will also accelerate it. There will be something api^arent in the physiognomy of the case which shows the man to be in a nervous and asthenic condition. Sometimes the pains from which the patient suffers in the back and the weariness in the limbs are so great that he remains a good deal of the time in bed. In all cases he will assert most positively that he is unable to work or to take that interest in his affairs that he has previously done. In a good many cases there will be added to the foregoing picture a number of symptoms due to some local injury : for example, the arm may have been wrenched or bruised, and the result may be a certain amount of neuritis TIIK Th'.lVMJriC NEUROSES. ?,09 and wcakiK'SS or pain in lliat nioinlxT; in otlicr cases the hack may Lave been so severely sprained tliat the typical symptoms of spinal irritation ensue, and this is pai-ticularly apt to he the case when Avomen are injured. In other eases, again, the lej^s may have l)een hurt to such an extent that a sciatica or some other form of neuralgia develops. The foregoing symptoms, varying in amount and degree, will last, with little change, for a very long period of time. If the case goes into litigation, there is added the worriment o(;(;asioned by having to go through the disturbing experiences of trial by jury. lu many cases, after the trial has been settled and damages awarded or otherwise, the patient begins to mend, and in a certain proportion of cases he gets com- pletely well. This is not by any means invariably the rule ; it may be said, on the contrar}^, that as a general thing a person who receives a serious shock to his nervous centers, residting in a genuine and grave neu- rasthenia, is i-arely entirely the same afterward. However, after a varia- ble period of months or years most cases get into a state of at least comparative health. Their nervousness gradually diminishes, their sleep improves, the pains successively lessen, the appetite is restored, the fieshi is regained, the power of work and enjoyment in life come back. MIXED TYPES. Traumatic Spinal Irritation. — Besides the foregoing general and common sjnnptoms of traumatic neurasthenia, it sometimes affects per- sons in other and special modes. For example, the sjanptoms of spinal irritation may predominate. These form the cases which were described b}^ Erichsen under the head of sjnual antemia aud hypertpmia. Their symptoms differ little from those described in systematic works upon spi- nal irritation. These patients are usually women. After receiving an injury which may have been slight and which may not necessarily have directly injured the spine, they very soon complain of pains in the back and 2)articularly the lower end of the spine and in the back of the neck. These pains are so severe that they soon give up attempting to walk about, and linding that they get some relief and comfort in bed they go there and there i-em ai n. While keepin g perfectly cpiiet the l;)ack gives them comparatively little discomfort, l)ut attempts to sit up for a long time, to ride, or to walk, cause such distress that they are speedily abandoned. The pains are of a heavy, aching eluxracter, increased until they become very sharp Avhen attempts at movement of Wia trunk are made. There is a great deal of ten- derness to pressure alongthe spinal processes, some of these processes bein^ much more sensitive than others. The most sensitive points are usually the back of the neck and the upper dorsal vertebrjT3, and down in the lum- bar region. There is some pain also upon pressure alongside of the spinal processes. Painful points often vary, and even in a single examination the patient may complain, and complain honestly, of dilferent si^nsitive vertebrae They suffer much from headaches. The arms are often weak, so that attempting to sew or write or hold a book causes pain in the neck and shoulders. The legs are also weak and the circulation poor. There is sometimes palpitation of the heart and precordial distress, A certain amount of dyspepsia is always pi-esent, and constipation is the rule. The patients often have attacks of vomiting, and attempts to feed them re- (piire much care. The menstrual functions become irregular, aud if it 310 ^ SYSTEM OF LEGAL MEDICINE. be a male tlie genital functions are weak, Tlie knee-jerks are exagger- ated; but there is never any true ankle-clonus. There is no ana?sthesia of the skin, and we rarely detect any anaesthesias of the special senses. I have never been able to find contraction of the visual field or of the aural field, nor do, in this country, the anaesthetic stigmata of hysteria present themselves. The patients are mentally very emotional and de- pressed. The}^ complain much al^out their pains ; they are irritable and exacting ; their sleep is very j)oor and often requires hypnotics. They have frequent intense headaches, which are usually of a congestive char- acter — that is to say, are associated with feelings of fullness in the head and throbbing, spots before the eyes, and ringing in the ears. If such patients have become thorough^ bedridden, their symptoms are ex- tremely aj)t to become chronic, and they form a very difficult class to deal with. After a time the legs waste considerably, and there may be even a certain amount of actual paralysis — that is to say, the limbs are too weak to support them and too weak to respond to any severe test of muscular strength. Electrical examinations, however, never show any of the evidences of degenerative reaction. Cases of this kind may con- tinue for two or three years, their sjanptoms then gradually ameliorate, and, as a rule, they get better, if not entirely well. A few cases continue with more or less painful spines and weak extremities for a great many years.* Hypochondriacal Neuroses. — There is another form of traumatic neu- rosis, wliich is, strictly speaking, a psychical disorder or form of hysteria. It is characterized by the existence of certain fixed ideas or a fixed idea regarding some morbid condition of the body. The special direction or 2Doint toward which the mind is fixed varies somewhat, being often de- termined in a measure b}^ tlie original injury. Sometimes it is simpty a 23ainful spot in certain parts of the bod}", such as the back or the head ; or it may be a painful joint, and develop into a so-called "hysterical joint" ; sometimes it is a morbid condition of the stomach or of the sexual func- tions which alarms and depresses the patient. The special symptom about which the patient's mind is centered is the only prominent trouble that he has, but it is generally associated with a certain amount of dyspepsia * TrciKviatic Fanctlonal Parali/ses. — There seems to be no doubt that occasionally patients suffer from functional paraplegia, which is essentially of spinal origin rather than cerebral. The cases resemble in many respects those jxist described. The pa- tients who suffer from this condition are generally women at the adolescent period of life, and their paralysis occurs in connection with symptoms of pains in the back and a general neurasthenic state. These cases have often been described under the heads of spinal ana'niia and of hysterical paraplegia. Bastian, in his work on Hi/sferical or Functional Parahjsis, believes them to be due to a functional disorder of the anterior cornual cells or of the pyramidal tracts in connection with the anterior honis. The paralyses of this kind are not by any means as a rule caused by trauma, but more often they develop gradually through the influence of overwork or some exhausting disease. Occasionally, however, they do develop after an inJTiry. In some there is a history of tuberculosis. The onset of the trouble is usually gradual. The patients suffer from a progressive eufeeblement of the lower limbs, associated with pains in the back and a sense of heaviness and weariness in the affected extremities. The <.'irculation of the lower limbs is somewhat feeble, and the skin looks white and feels «ool and clammy. Tliere is no decided muscidar atrophy, and there are no cpialitative changes in the electrical reactions. The knee-jerks and skin reflexes are usually ex- aggerated. No special group of muscles is affected more than others. There may be a little bladder weakness, but it is not serio;is or permanent. There is rarely any anaesthesia, and if present it is only very slight in grade. There is pain in the back THE TRAUMATIC NEUIIOSES. 811 and constipation, with a condition of iin]>airod nntrition, general weak- ness, a good deal of mental iiTital)ility, and always with mental depres- sion. The most searcliino' exaniinati(m of the bodily functions fails to discover any sign of organic disease or any evidence of sei-ions disturb- ance of the nervous function ; yet desi)ite this the patient incessantly (ioni- plains and talks continually about his sufferings. This immense dispro- portion between the sid)jective suifering of the patient and the objective jsyniptoms constitutes the cliaraeteristic feature of the disorder. It is not accompanied, I should add, with those stigmata which are associated with decided forms of neurasthenia. This neui'osis, which is also called JnjjMtrJioiidridsis, usually occurs in persons who have a psychopathic history — i.e., in persons who have always been self-centered and of a neurotic temperament. Cases of traumatic arthralgia and so-called topoalgia belong to this class. In connection with ti-auma true h3^pochondriases and arthralgias are in my experience rare ; though these conditions not infrecpiently complicate genuine neu- rasthenic states. A somewhat typical case of this form of disorder is the following : J. K., aged twenty-eight ; nativity, United States ; single ; occupa- tion, barten der. The patient gives a family history which is compar- atively free from neurotic incidents. His father suffered from chronic headache, but was otherwise healthy. There is no tubercidosis in the family. He himself had always been a fairly healthy man, though of a nervous and somewhat irritable temperament. He had megi-ainous head- aches, beginning at about the age of twenty-two. Tlu'ee and a half years before I saw him he had a fall through a trap-door. He got no severe injury and was not stunned. He got up and went about his work as usual. In the course of six or eight weeks he began to notice a jiain developing in the back between the shoulder-blades, which he put into relation with the strain experienced during the fall. This pain was of a dull, aching character ; it did not pass around the chest, but was con- fined to an area atiout the level of the fourth dorsal vertebra on the left side, between the vertebra and the scapida. The pain was constant, never disappearing during the day-time, not improved by posture, not sometimes, but not in the legs. Tlie i^aralysis may be incomplete, the patient being able to stand and take a few steps ; sometimes, however, it is so severe that t]ie]>atient is bedridden, although she never loses entirely the power of moving the lower limbs while lying in bed. After a time contractures take place in some cases and the legs are drawn np. Along with this a considerable amount of wasting occurs, but there are still no electrical changes characteristic of degeneration. The spine is tender to pressure, and tlie patient often suffers great distress in tlie back, particularly in the lower part and in the cervical region. The arms are usually unaffected. The patient presents absolutely none of the characteristic hysterical stigmata, such as anaesthesias of glove and stocking type, contracted visual field, pharyngeal anaesthesia, disturbance of smell and taste, ami hysterical crises. In fact, the picture of the case is very much like that wliich I have described Tinder the head of spinal irritation; the difference being only tliat the dominant sym]itom in this class of cases is the paraplegia, while flie spinal and other pains are simply associated with it. The patients often take a fair amount of food, though they are subject to digestive disturbances and attacks of 'S'oraiting. They have severe headaches at times. Tlie heart action is not strong, and the arterial tension is low. Such forms of paralysis are often very obstinate, lasting usually from one to four or five years. As a rule the patients get well, and an active, vigorous treatment is an extremely important factor in securing this end. In fact, tlie prognosis is vastly changed in accordance with the character of the therapeutic •measures which the i)atieut receives. 312 ^ SYSTEM OF LEGAL 2IEDICIXE. increased by movement or "vvork, and not relieved by rest. At times there were exacerbations of it, so severe as to render liim utterly mis- erable, tbongli thej^ never incapacitated Mm for bis work. His general health continued good. He was able to eat and digest his food, to sleej), and to perform his daily work. His habits were good ; be neither drank nor smoked, except in great moderation. No form of treatment produced tbe slightest effect upon the suffering, and at the end of three and a half years be was brought to me for examination. He was a man of strong and muscular build, somewhat thin in figm-e, but not emaciated in any degree. He presented some symptoms of a catarrhal dyspepsia, but other than that there were absolutely no object- ive symptoms, nor were there any of the marks of hj^steria. On ex- amining the painful area I discovered it to be located about as stated, between the thu-d and fom-th dorsal spines, covering an area of about two inches in diameter between these spines and the inner border of the scapula. Here there was some hj-per^esthesia to touch and some tender- ness on pressui'e. The pressm-e and manipulation of the spine produced no pain, nor could jDain be elicited by any movements of the trmik or shoulders. The pain was relieved only temporarily by injections of co- caine. It was not helped by cauterization, blisters, or counter-irritants of any kind. In fact, no local application or any internal medication did the slightest good. UNUSUAL TYPES. There are certain pecidiar forms of traimiatic neui-osis which cannot be classed strictly under any of the foregoing heads. These atypical forms of traumatic neui-osis have uot been observed in sufficient number as yet to enable us to make of them a tx])e. I shall therefore not at- tempt a systematic description of them, Imt shall place on record a case which iLLustrates veiy well the class of injury to which I refer, adding that in atj^ical forms the probability of simulation or exaggeration is always very gi-eat. A. D., aged forty-five, married, had alwaj^s been a strong, hard-work- ing, -^-igorous man of temperate habits, and without any history of alco- holism or syphilis or previous nervous disorder. In April, 1892, while standing in a car, he was thrown down in the aisle by the force of a col- lision. He was temporarily stunned, but got up, sat in his seat very much frightened, but unconscious of much injury. He got to his dejDot in fifteen or twenty minutes, then found he could not walk, and had to be lifted to a carriage which con^-eyed him to his home. His physician, who was then called, found that he had a contusion of the right parietal boss, severe pain in the lower part of the back, numbness in the left leg below the knee and in the right arm, in the course of the distribution of the ulnar nerve. There was no anaesthesia and no distinct paralysis, but rather a "^veakness of the legs and of the right arm. Tremor was also observed in the two upper extremities. The temperature was ninety- seven degi'ees. Xo bladder or rectal troiibles. He suffered considerable pain in the back and in the leg. He was placed in bed, and continued in about the same condition for a week or two, then gradually improved so that he could sit up and walk a little. During tins time he had chok- ing sensations at times. He slept and ate pretty weU, but was uer^-ous, THE TEA IMA TIC yELTlOSES. 3 "13 depressed, emotional, and irritable. He had durin^- this time a slijL^ht attack of herpes zoster over the eonrse of the rij^'ht twelfth dorsal nerve. He was seen hy nie al)out six months after the injur}'. The physical examination at that time showed him to l)e a man of good color, not ana'mie, well nourished. He walked slowly, using a cane, and spreading his feet apart. He was unable to stand with e^^es closed. There was no atroi)hy of any muscular groups in any of the extremities. He had a fine tremor of considerable amplitude, continuous in character, increased on extension of the arm, and slightly on volitional movement. There was some tremor in the legs and a very little in the face and tongue. On making him shut his ej'cs and show his teeth a pecidiar shai-]) con- traction of tlie platysma myoides was produced (perha|)S natural to him). The tactile, temperature, and pain sensations were all normal. There was a slight degree of ataxia in the legs, Imt none in the arms. There was a slight amount of tenderness about the region of the third and fourth lundjar vertebne. Pressure and the application of heat produced some wincing and reflex contraction of muscles near the spinous pro- cesses. He coidd move the back and trunk in all directions. Pushing on his legs caused pain in the back. This luml>ar pain never radiated around the waist or darted down the legs. There apjieai-ed to be cf)nsid- erable weakness in both legs, more in the right, and there was some weakness in the right arm as compared with the left. No fibrillary con- tractions. The knee-jerks were exaggerated slightl}^, but there was no clonus. There was also exaggeration of the elbow- jerks. Electrical re- actions of the leg and arm muscles were normal or slightly increased. There was no liypera?sthesia or tenderness except in the back. The special senses of smell and taste were normal. The hearing was normal except in the left ear, where he was deaf to high notes, bone and aerial conduction being good. The pupils w^ere small, equal, reacted to light and acconnnodation. Vision was good, and there was no contraction of the visual fields. The pidse was seventy-two and the heart action normal. The pharyngeal reflex was normal, and the choking-attacks which he had once suffered from had ceased. The urine was normal. He suffered from cold feet and some evidences of vasomotor weakness. The diagnosis at the time was a traumatic neurasthenic condition, plus some local injury to the spinal ligaments and to some of the nerves issuing between the twelfth doi'sal and first lumbar, and between the third and fourth lund)ar on the left side. This case, while to a large extent functional, was perhaps complicated with a certain amount of injury to spinal nerves, and certainly with much exaggeration. The patient got practically well. Special Symptoms. — Hjxvhig gone over the symptoms of the vari- ous tj^pes of traumatic neui'oses and given some illustrative cases, I pro- pose now to discuss some of the spe{;ial symptoms which we find in these cases, and which are more or less characteristic. First of all, I shall take up those symptoms which Indong to the psy- cJiicdl spJior, and which include mental irritability and depression, lack of attention, lack of power of concentrating the attention, feebleness of memory, and weakness of volitional power. Associated with these may be classed the headaches, vertigo, para^sthesia of the head, including such symptoms as insomnia, head-pressiu'e, feelings of constriction and fullness. Of these symptoms the insomnia is one which is perhaps most characteris- 314 A SYSTEM OF LEGAL MEDICINE. Diagrams showing in Figs- 34 and .35 the area over which a cutaneous irritation causes a reflex contraction of cremaster ; siiovving in Fig. 36 the areas over which a slight hlow produces a knee-jerli. P'roin a patient with a traumatic neurosis. THE TRAUMATIC NEVBOSES. 315 tic, and wliicli may be looked upon to a certain extent as a symptom of an objective character. Sleep is usually veiy much disturbed by bad dreams, and it is characterized especially by the fact that when the patients wake in the morning they have none of the sensation of restfulness that comes from healthful slumber. The emotion- ality and u-ritability of patients are alsa things which are usuaU}-^ noticed by others, and are in a measure objective. Little things, which never before annoyed the patient, now are become a som-ce of con- stant annoj-ance ; they get angiy at slight provocation, and become very disagree- able persons to live Tvith. They often cry over trivial circumstances, and also develop certain fixed and morbid ideas with regard to their condition and the future. The patient reacts very sensi- tively to stimiilants and narcotics. The Muscular and Motor Symptoms. — Tremor is a symptom which is very fre- quently present. It is fine in character and vibratory, and l^rought out best by making the patient extend the hands and fingers. It is increased readily by a slight amount of excitement and by narcotics and stimulants, such as tea, coffee, alco- hol, and tobacco. The muscular strength is somewhat reduced, as shown by dyna- mometer tests and by the attempts of the patient to do physical work. There is usu- Fig. 37. Eyes closed. Fig. 38. Eyes open. Ataxiagram showing SAvaying of body. ally a certain amount of wasting of muscles, but this wasting is general, and does not affect special groups. Questions as to the nornuil difference in the size of the extremities often arise. It has been found by measurements of normal adults that the size of the calves of the legs is equal in about one third of the eases, and that the right is larger than the left in about 316 ^ SYSTEM OF LEGAL 2IEDICIXE. one tliird, while the left is larger than the right in somewhat less than one fourth of the eases. The differences never exceed five eighths of an inch, and rarely reach that extent. (Walton.) The differences in the size of the arms are more considerable relatively, depending upon the occupation and habits of the indi'sddual, so that the exact figures cannot be given. Twitching motions of the face and a slight amount of fibrillary contraction take place. In these cases there is no locomotor or motor ataxia, but there is always in my experience a considerable degree of static ataxia, varjdng with the nervous dej)ression and irritability of the patient. This test for static ataxia I consider an objective one of considerable value. It must be made, however, by means of instruments of precision, which record aeciu-ately the amount of swapng of the patient with the eyes closed and with the eyes open. (See Figs. 37 and 38.) Something further will be said upon this point in connection with the diagnosis. The ten- don-reflexes are, as a rule, considerably exaggerated. This exaggeration is shown by the quick and extensi^-e movement of the feet on striking the patellar tendon, and by the fact that it can be brought out by strik- ing the leg on or below the knee-cap and on the quadi'iceps muscle above for a considerable extent. This extensive area over which a blow "wdll bring out a reflex contraction is an objective indication of nervous iiTi- tability of value in diagnosis. There is also an increase in the activity and extent over which the skin-reflexes can be brought out. This is particularly well studied in connection with the cremasteric reflex. (See Figs. 34, 35, and 36, on page 314.) Ill the sensory sphere there are a number of symptoms which eaU for special study. In traumatic neru-asthenia there is no anesthesia of the skin unless some complicating organic injiuy or some hysterical process be present. In this statement I know that I am at variance with the teachings of some of the German neurologists. Oppenheim in particular lays stress upon the fact that in traumatic neuroses there are conditions of slightly diminished cutaneous sensibility as well as genuine anaesthesia. This diminished sensibility or hypffisthesia is, however, one I have never been able to satisfactorily demonstrate in any except i)atients who pre- sented distinct hysterical marks of other kinds or in cases of organic neurosis, and the diificulties in the way of establishing a diminished sen- sibility which may be considered pathological are so great that the symp- tom is, in my opinion, even if present, one of little importance. There is a good deal of tenderness along the spine (in sixty to seventy-five per- cent, of cases) at various points ; also upon the scalj), particulaiiy at the sutm-es of the bones ; and sometimes in other i)ortions of the body. This tenderness on pressure is looked upon as an oljjective s}^nptom, and is, I believe, admitted as such in courts of law. When the test is properly applied it has a certain amount of value, because the patient Avill not al- ways wince properly if he is pressed unexpectedly on points that are not really tender, and because, on the other hand, the skillful apphcation of sudden pressure will bring out certain genuine manifestations of pain. In addition to that, there is in some cases a rather sudden acceleration of the pulse when a tender point is pressed. This symptom was first described by Mannkopf in 1885 and is called after his name. Its pres- ence indicates an undue irritability of nerve centers and has objective importance, though it does not show the existence necessarily of a trau- matic or other neurosis. THE TRAUMATIC NEUROSES. 317 318 A SYSTEM OF LEGAL MEDICINE. Visual TrouNes. — In traumatic neuroses without hysterical compli- cations there is, as a rule, no concentric limitation of the visual field. Still, slight limitation occurs in a minority of cases, and in nearly all in- stances in which the symptoms are of a severe type there is evidence of a certain amount of fatigability of the visual field. I mean by this that there are evidences of a ver}' easy tiring of the periphery of retina. The existence of this condition has been pretty well established by the labors of Forster, Konig, and others. My own experience is that in at- tempts to map out the visual field in these cases there is great conflict of statement on the part of the patients with regard to the position of the object that is moved before them, showing that their power of attention Fig. 40, showing Forster's "shifting-type" in a case of traumatic neurosis. The contin- uous line represents the field of Nasion as the test-object is moved from periphery to center; the dotted, as the object is moved in the reverse direction. is easily exhausted, and that their power of perception weakens along with it. In some cases one finds a general hmitation of the visual field of a moderate degree, as seen in the diagram, Fig. 39. In other in- stances one finds a condition which has been described by Forster and Konig, and is known as the Forster shlt'ting-type {ScMehungstypus). The characteristic of this type is that the field of vision which is mapped out by bringing an object from outside toward the center is greater than the field of vision mapped out by bringing an object from the center of "\dsion toward the periphery. If, for example, an object is placed to the temporal side of the right eye and gradually brought forward until it comes into the field of vision, it wiU be seen, we will say, at eighty-five degrees. The object is then brought gradually forward until it reaches the center THE TRAUMATIC NEUROSES. '319 of the visual field; it is held there an instant and then moved gradually- back. As it IS niovcnl back it Avill be lost to view, we will say, at eiglity degrees. The object is then moved in the same way on the nasal side, and above and below, with the same residt. An example of this is sliown in the diagram appended here. (See Fig. 40.) There is sometimes a disturb- ance in the color sense in these conditions, and we often find evidence of muscular asthenopia, especially loss of power of convergence. (Huebscher.) Other symptoms are a visual weakness, with at times spots before the eyes, ami i)ain and tenderness in the eyeballs and al^out the brow. Patients often complain of total inability to read for any but a very short time. Attempts to read produce headache, mental confusion, and a sense of prostration.* The sense of smell is sometimes found to be impaired or aboHshed after injuries of the head. It is, however, in most cases, if not all, au evidence of local disorder or of some actual organic disease. Thus, among twenty- two cases of head injury which were followed by anosmia. Von Bergmann found evidence of fractiu-e of the base of the skidl in ten. It is to be remembered, also, that anosmia is sometimes a sjanptom in tabes dorsalis, aud is sometimes produced by syphilis. Disturbances in the sense of taste are very common in hysteria, but not in traumatic neurasthenic conditions. In this latter class of cases there may be an undue irritability of this sense or some perversion due to local conditions or digestive troubles, but that is aU. The disturbances of the special sense of hearing consist of noises in the ear, hyperacusis, and sometimes slight deafness. Baginsky has de- scribed a deafness occurring in traumatic neurasthenia, and due to con- cussion of the labyrinth. It is associated with noises in the head and sometimes Avitli vertigo. It occurs especially after a physical injury. Sometimes vertigo occurs and becomes extremely annoying, and cases have been described in which the dizziness was so severe as to produce a condition resembhng Meniere's disease. In my own experience I have found ringing in the ear to be the most distressing and common sjaup- tom. This ringing is gencrall}^ continuous, not nmcli modified by post- ure, and not of ilic pulsating character, but rather continuous and per- sistent. There is no limitation of the field of hearing — that is to say, patients can hear very high notes and YQvy low notes — but in a considei-- able number of neurasthenics one finds a slight amount of deafness of bone conduction, generalh', however, in only one ear. Lari/ngeal iSijiJiptonis. — Benno Holz reports two cases of aphonia nerv- osa due to trauma and associated with paresis of the abductors. Paresis of this kind is rare, but does occur. Paralysis of the dilators of the larynx, however, has never been described and probabty never occurs. (H! Burger.) ^^a:^olllotor DisfKrlxowes. — In a large proportion of traumatic neu- roses one fiuds evidences of vasomotor weakness. This is shown in the cold hands and feet, the tendency to perspire easily, and sensations of heat and flushing. There is also in many cases a considerable degree of dermography. On drawing a dull-pointed instrument over the skin of the back or chest a broad red line will soon develop, which lasts some- * Wilbvand finds often some CL V Field in neurasthenia, bnt most others disaejrpe (Konific, Hochwardt, Topolanski). There is, however, not rarely a limitation of color- field, especially for blue, {yciir. Ccntralbl., 1893, p. 5S4.) 320 ^ SYSTEM OF LEGAL MEDICINE. times for half an hoiu', and is mneli more marked tlian in normal persons. This vasomotor distiu'bauce, however, is often found in healthy people, and may depend upon other things than a nenrasthenic state* There sometimes develops a local cyanosis of the extremities, so that the fingers or the toes become cold and white, and resemble the condition known as Raynaud's disease. A few cases have been reported in which a local edematous swelhng developed in different parts of the bod}^ after tramna. These local swellings are known as angionem-otic edema. They do not occur necessaril}'- near the part injui-ed. They develop rather suddenly in the form of circumscribed swellings, which are usually somewhat pale, though they may have a reddish tinge, and they do not pit on pressure. They may last for a few hom^s or daj^s and then disai3pear.t Traumatic neurasthenics are often liable to perspire excessively. This tendency to sweat is, however, not a uniform symptom, and at times there may be only a local sweating. Thus the patient complains of an area of profuse persj)iration in the small of the back, or on the legs, or perhaps only on one side of the body. Urticaria and eruptions of a sim- ilar character sometimes develop. (Kriege.) A case of bloody sweating has been reported by Ehrig. It occiuTcd in a trapeze performer, who fell and struck his head. The local bloody sweat took place on the head, and was accompanied by no other sign of sweating. The bodily temperature has been found at times subnormal, while others have described attacks of feverish character. In my own experi- ence I have found no marked or important changes in bodily temperatui'e unless there was an hysterical factor in the case. It is well to bear in mind, however, the experiments of Lehmann {Cenfrcdhlatt f. INerrenheiU:, May, 1890), who found that, by directing attention to the subject of bodily temperature, indi^dduals who were not pre\4ously hypnotized could raise the temperature as much as half a degree Fahrenheit. The pulse is often abnormally frequent in the traumatic neuroses, ranging from 90 to 100, and if not frequent it is apt to be irritable, so that slight physical exertion and shght mental excitement accelerate the beat of the heart greatly. This increased pulse-frequency and abnormal irritability of the heart constitute olijective symptoms which may be considered to have much j)ositive value in diagnosis. The average pulse in fifty-nine cases, as determined by Walton, was for males 90.5, and for females 95.75. This rapidity of pulse is a symptom on which German writers lay much stress, and Oppenheim has noted some cases in which as a result of persistent rapid heart-beat some dilatation and compensa- tory hypertrophy of the heart took place. The increased pulse-rate when pressure is made on a tender point has ah-ead}'" been referred to. The condition of the urine in traumatic neurasthenics is also some- what characteristic. It is apt to vary much in quantity, sometimes the patients suffering from poljoiria and again from a rather condensed Tirine. There is at times an irritable bladder and tendency to frequent * Ludwig Man {Berlin KUn.TVochenschr., July, 1893) finds a lessened electrical re- sistance of the head in tranmatic neuroses. He uses small electrodes and weak cur- rents (3 elements). He puts one electrode on the neck, the other on the forehead. He finds the normal resistance 4000 to 6000 ohms ; in neuroses, 1500 to 2500. Eulenberg, using larger electrodes, 6x12 ctm. and 10 elements, finds the normal only 1200 to 1600. t Guinon reports a ease of blue edema with anaesthesia after a fall. (Op. cit.) TUE TRAUMATIC NEUROSES. 321 micturition. The urine in most eases presents a relative excess of plios- phates, and the earthy phosphates in jjarticular are increased disprcjpor- tionately. Methods of Examination and Diagnosis. — I have not space to go over in detail all the methods wldch are reqnired in a thorough exami- nation of a case of traumatic neurosis or traumatic neurasthenia. The details of these methods are given in text-books on nervous diseases. It will be sufficient for my purpose now to give simply an outline of the general plan to be pui'sued, and then to call attention to certain special methods which are of importance in the determiuation of objective symp- toms and in the detection of simulation. The physician wlio is examin- ing a patient should proceed in a certain regular and systematic way. An outline of the plan to be followed is given in the accompanying scheme : 1. Preliminary facts : name, age, sex, condition, nationality, occupa- tion. 2. Family history. 3. Personal history. 4. History and causes of present disease. 5. Physiognomy of case. General appearance, nutrition, abnormalities, gait, etc. 6. Disorders, if any, outside of nervous sphere. Digestion, heart, lungs. Temperature, respiration, pulse, urine. 7. Psychical sphere : mental condition ; sleep, etc. 8. Motor sphere : paralysis ; tremor ; abnormal movements ; atrophy ; -electrical and mechanical reactions of muscle and nerve ; speech. 9. Sensory sphere. General sensations : vertigo ; pain ; paraesthesia. Special sensations : tactile, temperature, pain, muscular (ataxia) ; vision j hearing, taste, smell. 10. Reflexes superficial, deep, organic. 11. Trophic, vasomotor, and secretory disturbances. The examiner should bear in mind the importance of weighing all the evidence as impartially as possible ; of allowing only the proper weight to the statements of the patient ; of securing evidences of organic disease, evidences of conditions which the patient cannot simulate ; and he should bear in mind also that while the patient may be perfectly sincere he has so much at stake that he will often exaggerate. It is well to secure a careful history of aU the details of the accident, and to have the history corroborated from several sources. The facts \vith regard to the condition of the patient subsequent to the injmy should also be gathered with the greatest care. The physician must in all cases assume an attitude which is not sympathetic but critical ; he must, even, perhaps, at the expense of a certain apparent unkindness, investigate every statement and every phenomenon that is presented in connection with the case. He should also take especial pains to inquire into the previous health of the patient. It has been found by Walton that in seventeen out of a hundred cases there was some nervous or oi-ganic disease before the injury occurred, and investigations by other authorities have led to similar results. Having secured a full and complete history of the case, the j)hysician proceeds to the direct physical examination of his patient. For the pm'pose of carrying out such an examinatiou in all 222 ^ SYSTEM OF LEGAL MEDICINE. its details a considerable immber of appliances are necessary in many- cases. The following- list may be perhaps of some use to those who de- sire to equip themselves for this kind of work : a stethoscope ; appliances for examining the mine ; a galvanic and faradic batter}^ with milliam- peremeter, sponge electrodes, and a wire brush with interrupting-handle ; a dynamometer, esthesiometer, and ophthalmoscope ; a perimeter ; a Gal- ton's whistle; a tuning-fork; a percussion-hammer; and materials for testing the senses of smell and taste. In addition to these one may sometimes have use for a sphygmograph, and in my own work I am ac- customed also to use special dynamometers for the legs and extensor muscles of the arms ; a concealed needle for testing the sense of pain ; metal tubes one centimeter in diameter, which are used in testing the cold and heat sense according to Goldscheider's method; weights for testing the muscular sense ; a bass-viol string for testing low notes ; an instrument for testing ataxia and measuring its degree ; also an instru- ment for testing slight degrees of tremor. Anatomical. — Preliminary to a detailed description of methods of examination, I have thought that it would be helpful to the reader to in- sert some anatomical diagrams which could be referred to in the course of an examination or in preparation for it. Fig. 41 illustrates the com- parative size and relations of the brain and spinal cord as they appear when removed together from the body. Fig. 42 shows the relations of the brain and cord in their normal position in the body. Fig. 43 shows the points of exit of the cutaneous branches of the spinal nerves. Fig. 44 shows the positions of the spinous processes of the vertebrae (indicated by the squares), the point of exit of the spinal nerves (indicated by the horizontal lines), and the relation of the points of origin of the spinal nerve roots (indicated by the dotted hues) to the spinous processes. Thus the third lumbar nerve is seen to originate at a point between the tenth and eleventh dorsal spines. Figs. 45 to 52 show the normal dis- tribution of the sensory nerves, and are of help in mapping out the dis- tribution of anesthesia, and in determining whether this corresponds to the area of any given nerve or nerves. Such facts are of importance both in localizing lesions and in questions of diagnosis between organic and hysterical troubles. (See Traumatic Hysteria.) It is customary, before proceeding to test the condition of the nerv- ous system, to examine the other organs, and some points may be given here with regard to this matter. Tests of Heart Action. — I have already referred to the fact that the heart-beat is sometimes abnormally rapid, and to the fact that pressm-e upon a tender point, particularly one near the spine, wlQ produce an ac- celeration of the pulse-rate. According to Mannkopf such pressure will raise the pulse from 84 to 92 or from 100 to 120, and this acceleration lasts for two or more minutes ; the pulse also gets smaller. This test is known as the neuralgic cardiac reaction. In examining the pulse it is im- portant to feel the two radial arteries or the two carotids or the two femorals at the same time, the physician placing a finger of each hand upon the two arteries. In this way he can determine whether the pulse on the two sides is synchronous, and may possibly detect the presence of an aneurism. The sphygmograph will in my experience usually give a curve of low tension and one that is somewhat characteristic of the neu- rasthenic heart. I have taken the tracings of twelve typical cases of 324 A SYSTEM OF LEGAL MEDICLNE. neurasthenia and superimposed tliem, producing as a result a sphygmo- gram, wliich. may Le considered to represent the neurasthenic type. The characters of the urine in traumatic neurasthenia I have referred to already under the head of Symptoms. Tests for phosphates, both earthy and alkaline, for al- bumin, casts, sugar, uric acid, and indiean should be made. Tests for Motor Nerves and the Muscles. — The existence of tremor or spasm is of course easily determined. It is very important, however, to study carefully the char- acter of these disturbances. The tremor is usually of a fine and vibratory character, the rate of vibration being about ten per second. It is best produced by making the patient extend the hand and spread out the fingers. It does not increase on volun- tary motion, and is ^^ery slight when the patient's extremi- ties are relaxed and qidet. The head is not affected, and when there do oceiu" some- oscillatory or nodding mo- tions of the head it is sig- nificant of some hysterical condition or some serious neurosis. Slight muscular twitchings of the face and extremities are not at all rare symptoms, and are of some importance as indicating motor irritaliility. When a paralysis exists it is of ex- treme importance to deter- mine whether it be of a func- tional or oi'ganic character. The points for determining this are given in detail also in standard works on neu- rology, and they cannot be entered upon fully here. It is important, however, to bear in mind that in functional palsies there is little or no atrophy, and that the same fact applies to palsies due to brain disease, except in children. A certain amount of wasting occurs in the limbs from disuse, but in my own experience this. Fig. 43, showing the points of exit of the cutaneous branches of the spinal nerves. (Van Gehuchten.) Fjg. 44, showing the position of the spinous processes vindicated bv the squares), the points ot exit ot the spinal nerves (indicated by the continuous lines), and the points of origin Of each nerve (indicated by the dotted lines). Thus the tifth lumbar nerve originates at a point be- tween the eleventh and twelfth dorsal spines. Drawn from a photograph of a man on wh^ these points had been mapped out. 325 rhom 326 ^ SYSTEM OF LEGAL MEDICINE. rarely exceeds liaK an inch for the leg, and hardly as much for the arm. (See p. 316.) The most important means of determining the organic char- acter of a paralysis is by the nse of electricity. I feel very confident that I am correct in stating that degeneration reactions are never f onnd when the paralysis is of a functional type, and that they do not occur in hys- teria uncomplicated with organic disease. By a " degeneration reaction " I mean a diminution in the contractility of the muscle to the faradic cur- rent, with a peculiar sluggishness of reaction when the current is passed through the muscle. Sometimes there are changes in the relative excita- bility to the two poles, so that the positive pole on closing the current gives a stronger reaction than the negative ; and sometimes the contrac- tion is not only sluggish but diffuses over the whole body of the muscle. 'There are, I believe, some electrical changes which to a certain extent are ■characteristic of a neurasthenic state — that is, of a state of irritability and weakness of the nervous centers. I think, however, we cannot yet posi- tively formulate what these are. Rumpf has laid down three tests for the traumatic neuroses : first, pressure on painful points, giving rise to accel- eration of the pulse (Mannkopf's symptom) ; second, a quantitative reduc- tion in galvanic irritability of motor nerves ; thu'd, a fibrillary contrac- tion of the muscles, which lasts sometimes after the current has passed through them, and which extends into adjoining muscular groups. This he calls the traumatic reaction. The second symptom occurs only late in the disease, that is to say, one or two years after its inception. He finds, for example, that in the normal ulnar and peroneal nerve the Ka C C (negative pole closure-contraction) is produced by ^ to 2 milliamperes, in a traumatic neurosis by 4 to 10 milliamperes ; the normal Ka C Te (negative pole closure-tetanus) is produced by 4 to 11 milliamperes, that in the traumatic neurosis by 20 to 25 milliamperes. There is in the traumatic neuroses an abnormal degree of muscular weakness ; the patients tire easily and are incapable of theii' ordinary amount of physical work. This symptom, of course, is easily simulated, and is one that is almost always complained of by malingerers. A test for the genuineness of this symptom has been described by Wichmann ; it consists in sending the patient to an institute where appliances exist for measuring the muscular strength of the different groups, and oblig- ing him to go through various exercises. He is watched while this is done, and the records that he is able to make are compared with the normal. The observation of the patient at this time is also often help- ful ; for a geniune neurasthenic who wants to get well will do his best at the work laid down for him, while the simulator is constantly groan- ing and complaining at the distress that every effort causes him. Tests for Sensory Symptoms. — The subjective complaints of pain and of tenderness are always very great and prominent symptoms. The method of testing it by the " traumatic cardiac reaction," or Mannkopf's symptom, has already been described. Pain along the back occurs in about two thirds of the cases, and is always a matter of especial concern to the patient. The physician in examining the patient finds tender spots along the spine, and these spots will sometimes vary even during the single examination. This variability of tenderness used to be considered a sign of malingering, but I do not believe it always is, since it will be noted in neurasthenics who have no object for deceit. However, very gross and persistent changes in the location of pain may be considered THE TEALMATW XECIiOSES. 327 328 A SYSTEM OF LEGAL MEDICINE. suspicious ; so also is tlie absolute aud uuif orm localization of pain- ful spots on the same vertebra at different examinations. In testing for painful spots the physician should, however, always make it a point to distract the patient's attention, for if he finds that a place which was asserted to be extremely sensitive on pressure can be vigorously punched when the j)atient's attention is distracted, it is usually an evidence of either mahngering or some very hysterical state. The tenderness of the skin and of the parts beneath should be separately examined. Anesthe- sia of the skin in its different degrees should be tested by means of the aesthesiometer, by which tactile and pain senses are determined, and with hot and cold tubes, by which the temperature sense is determined. In Fig. 4T. Fig. 48. Fig. 49. ptron-.prirf. Fig. 51. testing for anaesthesia to pain (analgesia) it is not sufficient to use simple pricking-instruments, but the strong faradic brush should be emploj^ed. It is sometimes a good plan also to use a large wire brush, one part of which is laid over an alleged anaesthetic area, the other extending over the non-antesthetic area. The current being turned on, the brush can be tilted so that at one time it touches the anaesthetic part and at another time not, and in this way malingering can sometimes be detected. In testing the sense of cold and heat Go]d.scheider's method may be at times employed to advantage, and objective symptoms can in this way be de- termined. The test of the cold sense is made with metal cylinders at TUE TRAUMATW NEUROSES. 329 from 59° to 63° F., that of the hot sense witli cylinders at from 113^ to 120° F., the patient's eyes being- closed. Tiring- and cooling of the skin aifect tlie results. The latter will correspond most closely with (iold- scheider's noi-mal tallies when the cutaneous tem})erature in the first in- terosseous space of tlie hand or foot is from 85° to 86° F. The examina- tion begins with tlie test of the cold sense, a maximal point being tested. If the patient feels no temx)erature, but merely a sensation of pi-essure, then there is anaesthesia of the cold sense, whose limit and intensity must be determined. The intensity is tested by maximal temperature irrita- tions. For the cold sense a temperature of the metal cylinders of 50° F. suffices. But when the cylinder placed on the maximal point produces a sensation of temperature, the question is whether it is normal or weaker. Therefore the mininuil point is next tested, aud if this is likewise given correctly the sense of temperature is normal. But if disturbance is found — diminution (hypa^stliesia), hypertx'sthesia being very rare accord- ing to Goldscheider — its degree must be ascei'tained l)y comi)arison with symmetrical points or with equivalent other points of the table.* Visual Teds. — It is of course best in many cases to have the eye care- fully examined by a competent ophthalmologist ; the neurologist, how- ever, in particular determines the condition of the muscles and of the visual field and also the visual acuity. As ah'eady stated, there is often a consideral^le degree of weakness of the adductor muscles. This is tested with prisms and colored glasses, and by means of them often the efforts of the patient to deceive may be detected, particularly if this patient feigns serious disturbances of A^sion, such as diplopia or amblyopia. The de- termination of the visual field is made by means of the perimeter accord- ing to the methods ordinarily described in the text-books. In my ex- perience there is no contraction of the visual field in ordinary cases of traumatic neurasthenia ; but there is, as I have already stated, some de- gree of retinal hypa?stliesia in the peripheral portion, so that objects are not seen as distinctly or as long in the outer limits of the visual field. I can confirm the statements of Konig and Wilbrand aud Forster with regard to the existence of the shifting-type in traumatic neuroses, as de- scribed above. (See Fig. 40.) It is not present, however, in aU cases. In testing for the field of vision the examiner should use a perimeter for near objects, and then should confirm his findings by testing ^xiih. objects at a considerable distance. In this way attempts at simulation may be de- tected. With regard to the other special senses I have already said sufficient under the head of S3'mptoms. The tesfiiu/ of tlie rejiexcs and of the muscular ii-ritability is a matter of much importance. As a rule, the deep reflexes are exaggerated ; when they are not, I have generally found that there was either a history of alcoholism or some infectious disease. The skin-reflexes also are apt to be exaggerated, and the })eculiar enlarged area over whicli the cremasteric reflex can be elicited has been already described. (See Figs. 34, 35, and 30.) In intercostal neuralgia it is stated by Seeligmiiller that the abdominal reflex on the affected side is exaggerated. In testing for ataxia one should try to detennine the power of the * Goldselioidei-'s table and figures are published in the Archiv. fiir rsychiatrie, vol. xviii., 1887. 330 ^ SYSTi:2I OF LEGAL MEDICIXE. patient to stand steadily T\dtli the eves open and then ^vitli the eyes closed, the heels and toes being placed together. The patient should also be tested as to his power to place the extremities in different positions, touching different parts of the body with the eyes closed, and as to his knowledge of the position of his limbs when the eyes are closed, and also as to his ability to determine different weights. The question now comes finally as to whether there are any single objective sjnnptoms by means of which we can say that the patient has a traumatic neurasthenia. My own belief is that there are objective sjTuptoms whose existence shows that the patient is not simulating, but has some real morbid condition. There is, however, no single objective s^nnptom upon wliich we can alone rely.* The aggregation of all the objective spnptoms does not prove that the patient has a traumatic neu- rasthenia, but does prove that he has some morbid condition whose exact nature must be determined by the history of the case. Practically the object of the examinations in most cases is to determine, first, whether the patient is simulating, and next whether he has organic or functional disease, and finally, if he has only functional disease, what the exact nature of that trouble is. Now, as to the last point, we can say that it is traumatic nem-asthenia. We find that the patient suffers from the pe- cuLiar psychical anomalies referred to, the subjective sensor}^ disturbances, the insomnia and cerebral paraesthesia, and such objective spnptoms as muscular weakness and irritability, tremor, static ataxia, exaggerated reflexes, accelerated pulse and cardiac iiTitability, vasomotor disturbances, disturbances of the ^dsual field and am-al field. I do not mean to say that it is necessary that the patient have all of these sjTnptoms, and it must be left to the experience and judgment of the physician to deter- mine the weight to be placed upon them. Pathology and Pathological Anatomy. — There is not very much use, in my opinion, of speculating as to the pathology of the morbid state known as traumatic neurasthenia. It appears to be a condition in which there is an excessive weakness and irritability of the cells of the central nervous system ; those groups of cells controlling and regulating the cu-culation of blood — that is to say, the vasomotor system — being particularly affected. There have been up to the present time but few cases of post-mortem examinations made in traumatic neuroses. In 1875 Willigk reported the case of a boy of nine who had a fall and received a severe injury upon the head. He developed some s^Tuptoms of a neuras- thenic and iij^sterical character. He died, and the post-mortem showed some softening in the pons. The case is e^'idently not one in point, though often quoted under the head of the pathology of traimiatic neu- roses. Oppenheim (23) in 1888 reported an autopsy upon one case. He found no lesion, but there was no microscopical examination made. In 1889 Sperling and Kronthal reported a case of a man who at the age of forty-two received a slight injury in a raih-oad collision, followed at once by sjTnptoms of traumatic neurasthenia. The man gave no history of syphihs or alcoholism. The history, however, of his s^Tuptoms was im- perfect, and on post-mortem they found a high degree of arterial sclerosis, especially of the brain and cord, and a peculiar degeneration of the sym- * The contraction of visual field, rapid pulse, anaesthesia or hypa?sthesia, and psy- chic anomalies are characteristic and objective symptoms according to Oppenheim. THE TRAUMATIC NEUROSES. 331 pathetic system. Small insular patches of sclerosis of slight degree were fonud in all parts of the white matter of the cord, with degeneration of ganglion cells in a small area in the lower dorsal region, including Clarke's columns. There was a small hemorrhage in the middle of the dorsal cord. Bernhai-dt and Kronthal re})ort a case of a man aged thirty-three who was struck in the epigastrium by a horse's hoof. He suffered from a severe degree of hystero-neurasthenia for three years, and finally hung himself. The cord only was examined. Some slight arterial thickening and numerous patches of sclerosis were discovered in the white matter of the spinal cord. The patient had passed blood and vomited it, but there was no lesion found in the stomach or intestines. Schmauss has reported the case of a man aged twenty-nine who fell from a ladder and gradually developed the symptoms of a combined systemic degeneration of the spinal cord. There was, however, an imperfect his- tory of the case. Schmauss also rej^orts the results of some experiments upon animals, which do not throw very much light on the pathology of the tramnatic neurosis. Friedmann in 1890 reported two cases of head injury, occurring in a man of twenty-seven and a woman of thirty. The injuries were occasioned by falls, and were followed by sjmiptoms of meningeal irritation, with paroxysms of excitability. In the first case there was a paralysis of one of the cranial nerves. After death no gross lesion was discovered in either case, although it had been supposed there was some pachymeningitis. The microscopical examination was made in one case only. The blood-vessels were found to be distended and sacculated in places, and filled with blood. The perivascular spaces were dilated, and there were blood pigment and round cells in them. There was also found a hyaline degeneration of the walls of the blood-vessels — in fact, the record is suggestive of a syphilitic process. THE GRAVE TRATOIATIC NEUROSIS. In some rare cases severe traumatism may be followed by the produc- tion of a series of symptoms which partake partly of the natiu-e of neuras- thenic or hysterical disorder and partly of the natiu-e of organic disease. The neurasthenic and hysterical symptoms are much like those observed in the traumatic neuroses of other types. The additional symptoms, which suggest the existence of actual organic lesions, are such as have been observed in the condition known as disseminated sclerosis of the brain and cord. The exact nature of these cases has yet to be definitely settled. There is a steady and even gradation between cases of severe traumatic neurasthenia, traumatic hysteria, and the gi'ave traumatic neurosis sclerosis; just as it is often exceedingly difficult to draw a shar]) line between the very exaggerated type of traumatic hysteria and a case of what seems to be a disseminated sclerosis. These cases, how- ever, are extremely rare, at least in this country. In my own expe- rience I have seen but a few. The causes of the development of this form of ti'ouljle are traumatisms which are particularly severe ami in which the head has been also injured. I do not believe that such a disorder can be produced by psychical shock alone. The trouble seems to affect men oftener than women, just as is the case with major hysteria, and it occiu-s usually in persons who have reached the thii-d or fourth 332 ^ SYSTEM OF LEGAL MEDICINE. decades of life. The symptoms develop hi some cases very rapidly after the injiny is received. The patient suffers from headache and vertigo ; meiitally he is depressed, irritable, hypochondriacal, although this mental state I do not find always to exist. Sometimes the patient is rather hopeful, but is at the same time emotional and perhaps a little childish. The mental power in each case, is lessened. Either soon after the at- tack or some months later he develops tremors of the extremities and tongue, speech becoming somewhat thick or syllabic. Nystagmus may be present. The tremor is coarse and jevkj in character, large in range, and increases on voluntary effort ; in other words, it resembles that ob- served in multiple sclerosis and also in some forms of hysteria major. There is exaggeration of reflexes, as a rule ; no paralyses, however, occur. There may be some incoordination and some cutaneous anaesthesia, which is usually not limited to one side of the body. The visual fields are limited, and occasionally there is optic atrophy. There is also at times limitation of the auditory field and disturbance of the sense of taste. Sometimes there is lack of control over the bladder, and the patient may suffer from pain and stiffness in the back. These symptoms progress until they reach the stage which practically incapac- itates the patient from work, although he is not alwa3''S bedridden, and finally he presents the picture very much of a case of disseminated scle- rosis. The organic changes underlying the trouble are those of minute spots of sclerosis in the brain and cord. My own opinion is that at present we must consider these cases as belonging to the type of multiple sclerosis described in systematic works. It will be found that very few cases of this disorder occur which are not preceded either by an infective fever or by some severe trauma. A good illustration of a traumatic neurosis of this type is the following. The history of the case has been kindly prepared for me by Dr. Joseph Collins, under whose care the patient is. F. M., aged fifty-seven ; born in Ireland ; laborer. Family History. — No phthisis, rheumatism, insanity, epilepsy, nor hereditary predisposition. Previous Illness. — With exception of a fever when a young man, has never been ill; has always been as sound as a "paving-stone." Hygiene and Habits.— Has been twice married, childi'eu healthy. Has never had venereal disease. Alcoholic in a moderate way aU his life. Present Illness. — Two years ago, while riding on a load of hay, fell, struck on head, was carried to St. Vincent's Hospital, remained uncon- scious for two days, and when he recovered consciousness was in a dazed condition for a day or two longer. He remained in the hospital for two weeks. When he left there he was weak and '' shaky." He was unable to go to his ordinary occupation, but got light work about a stable. In less than a month after leaving the hospital he noticed that his hands were very unsteady and that it was necessary to use both of them to carry a cup or glass to the mouth. The shaking and weakness were more in the left hand and arm than in the right. At this time he noticed also that his hearing was gradually becoming impaired, and this impairment steadily became worse. He remarked also (one month after the injury) that there was some impediment in speech ; the words did not come regu- larly, as before. These symptoms, particularly the shaking of the hands and the trembling of the voice, he noticed were considerably increased by TUE TIUUMATIC NEUROSES. ?i^?, excitement, and less so by fatigue. At tliis time very little continuous etfort cans('d fati^'ue. Always in cold weather lie felt Avorse. Altliough the appetite remained good, and bowels and l)ladder regular, he could not gain strength. He did not suifer headache, dizziness, or pains. He has noticed that it is very difficult to make him perspire. AVhen he takes alcohol (which he does but rarely, on account Of being in hospital) he feels better, and the tremor is not so marked. Exammation — Appearance. — Poorly nourished. Face always the seat of a passive, dark, sluggish flush. Countenance not expressive. station and Gait. — Both good. Does not have tendency to fall. Tremor. — Slow, rate 24 to 27 in ten seconds, increased by fatigue, such as from holding his hands out for a minute. Amplitude extensive, and becoming more so on fatigue and on voluntary effort. Both upper extremities are affected, left side considerably more than right. In lower extremities mostly in left. Moderate tremor of head, winch does not reach nodding. Reflexes — Knee-jerls. — Both lively. Left very moderately increased. Slight ankle-clonus of left ankle. Eyes. — No nystagmus, either on movement or rest. Slight arcus senilis. Flecks of degenerative arcus irregularly distributed throughout cornea. Mobility of eyeballs not impaired. Pupils small, area of mo- bility small. React to light and accommodation. Pupils remain regular on accommodation. Considerable contraction of visual field of both eyes. 8ensation.-r-'Blxa\img of cutaneous tactile sensibility ; a sharp jiencil feels like the finger, and he says he cannot distinguish the contact of cot- ton from contact of piece of soft rubber. Pain conduction not delayed nor diminished. Discrimination of various tactile irritations very poor. No hyperaesthesia. Subjectively has para?stliesia in extremities at times. Hearing. — Can just hear tick of watch when brought in contact with left ear, but not in right ear. Bone conduction appai-ently diminished. Pulse. — Regular, 78 ; moderate capacity, slight increased tension. Temperature. — Slightly subnormal, 98° F. Speech. — Markedly scanning, and biting of syllables. Tongue not particularly jerky. Has trouble in starting speech. Mental. — Hopeful, never complains ; satisfied and complacent ; mem- ory defective. Physical. — Extremities rather weak, poor grijj, and weak resistance of extensors and flexors. Diagnosis. — The physician who is called upon to examine cases of this kind must determine whether they ai"e cases of hysteria major, paralysis agitans, disseminated sclerosis, or are simulators. The exist- ence of hj^steria major must be tested by the rides which will be laid down later. Paralysis agitans is in some instances caused by shock or injury ; its characters, however, are siifficiently definite to enable us always to distinguish it. The tremor is segmental, and is most marked during rest. It involves one side of the body more than the other, and rarely the face. There is no speech-disturbance and no nystagmus. There is a gradual development of muscular rigidity with the tremor. The patients also suffer nnicli from sensory disturbances, such as pains along the course of the nerves, sensations of heat, and numbness or prickling. The voice of the patient becomes feeble, high-pitched, or senile in char- a^cter. There is a peculiar flush of the face due to vasomotor paralysis. 334 A SYSTEM OF LEGAL MEDICINE. The detection of simulation mnst be made out by the methods described later. It would be very difficult for a patient successfully to simulate the coarse intentional tremor, the syllabic speech, and contracted visual fields of this disorder. Prognosis. — The prognosis in this class of cases is bad. The patients reach a certain stage in which they are able to be about, but are of little use to others or to themselves. They do not suffer much pain, and some- times are hopeful and cheerful. Reaching this chronic stage, the disease progresses very slightly, and they may live for many years ; but recovery is extremely rare, and if it occurred we should be obliged to consider that a large part of the symptoms were hysterical. Pathology. — It is becoming more and more my conviction that all cases of multiple sclerosis are either traumatic neuroses or are the re- sult of acute infectious diseases. The j)athology, therefore, of the grave traumatic neurosis would be nothing different from that which is usu- ally described as the pathology of disseminated sclerosis due to other causes. If any actual organic disease exists in this class of cases it must be one that is produced by small multiple hemorrhages which set up foci of softening, followed by a reparative process that leads to the develop- ment of small connective-tissue nodules in the brain and to a less extent in the spinal cord. It is not my purpose to go further into the descrip- tion of a process of which full accounts are given in systematic text-books. It may be said, however, that the anatomical condition underlying a traumatic multiple sclerosis is more favorable than that underlying one that follows infectious fevers, for the reason that in the latter case some microbic poison may be associated with the development of each diseased focus. In both forms of trouble there seems to be the same tendency for the nodules of sclerosis to be situated most frequently in the white matter, especially in that of the pons, internal ca]3sule, and centrum ovale. The cranial nerve roots are sometimes affected and also the spinal cord, but the diseased process is essentially a cerebral one. TRAUMATIC HYSTERIA. Hysteria is a chronic functional brain disorder characterized by nerv- ous attacks or crises, and by a peculiar interparoxysmal state in which .certain marks or stigmata are present. There are two forms of hysteria, the hysteria minor and hysteria major. Hysteria minor is that form of the morbid condition which is generally meant by the term hysteria. It is the hysteria of popular conception and of general medical parlance. In hysteria minor there is simply an exaggeration of the emotional side, together with outbreaks of various kinds, such as crying or laughing, fainting-attacks or convulsions. This minor hysterical condition is pres- ent in men and the great majority of women, and it is not always to be considered a disease. It is, however, when associated with neurasthenia or with other neuroses, often an unpleasant and disagreeable complica- tion. It is not of the hysteria minor that we speak when we use the term traumatic hysteria. Traumatic hysteria is really a major hysteria, and it is a definite disorder, quite different in its essential characters from that- malady which is popularly understood as hysteria. In hysteria major there is a decided and serious disturbance of certain special functions of THE TRAUMATIC NEUROSES. 33.3 the brain. As a result of tliis we have severe crises or attacks, during which the patients exhibit convulsive or other explosive phenomena, and we have between these paroxysms very striking symptoms, consisting of anaesthesia, paralyses, contractures, ti-emors, peculiar mental conditions, and even vasomotor and troi)hic disturljances. Traumatic hysteria majcjr is essentially the same disease as hysteria major due to other causes. In making- a study of the aiuesthesias of twelve cases of major hys- teria some years ago I found that four of them were of traumatic origin, and the clinical history of these four cases was not essentially different from that of the other eight. In a description of traumatic hysteria, therefore, I shall have to go over, to a certain extent, the same gi'ound that woidd be taken in the systematic description of this disease. Let me say now that in using the term hysteria in this connection I shall mean, unless I specify otherwise, hj'steria major. Age. — The traumatic form of hysteria occm-s chiefl}^ in middle life. Berbez found the average age of 21 cases to be 25 years, the range being 19 and 56. Thorburn found the average age to be 31 among 17 cases, being 28.} in the female and 35 in the male ; the range was from 18 to 42. Among 16 of my own cases the average age was 33, the range being from 14 to 54. The age of the female cases is younger than that of the male. Sex. — The disease occurs oftener in men than in women. This is the experience of Berbez, who found 14 males to 7 females, and in my own cases, where there were 11 males to 5 females among 16 cases. Thorburn would explain this on the ground that more men are injured than women in railwaj^ accidents. Few of my cases, however, were railway cases, but were injured by electric shocks, by falls, or blows. Thorbui-n states, however, that among 228 persons injured in railway accidents there were 157 males and 71 females. Among the former there were 10, among the latter 13 cases of hysteria, so that he estimates that the probabilities of a railway accident being followed by hysteria are three limes as great in the female as in the male. Thorbm-n probably uses the term hysteria in a less definite sense than I do. In my experience hysteria major is rarely found in women who have suffered from railway accidents. They more frequently develop spinal irritations, functional spinal palsies, and hysteria minor or neurasthenia. Marriage has no effect upon males, but unmarried women ai'c perhaps somewhat more susceptible than the married. Race. — Hysteria of the major type is apparentl}" much more common in France than in other countries. English observers state that it is rarely seen in that country-. In Germany it seems to be a relatively fre- quent traumatic neurosis. In this country traumatic hysteria is less frequent than traumatic neurasthenia. In Walton's experience the per- centage of hysterical cases was 17 ; in Knapp's, 15. In my own experience I have had an apparently unusual percentage of hysteria, for I found that among 33 carefully recorded cases of traimiatic neuroses 16 were cases of lij' steria. About one third of these were of German or of Russian origin, one fom-th of Irish, and the rest were of American parentage. Chronic alcoholism predisposes to a development of traumatic hysteria. Every year I find in the alcoliolic cells at Bellevue one or two cases of typical hysteria occurring in chronic alcoholics who have been subjected perhaps to some blow or shock. Traumatic hysteria, however, occurs in persons of perfectly temperate habits, and in most of my traumatic cases 336 A SYSTEM OF LEGAL MEDICINE. no history of alcoholism was noted. Traumatic hysteria occurs more frequently among men of the lower social class — that is to say, among laboriug'-men and mechanics and men who are subjected to hard work and privation. The influence of heredity has been much dwelt upon by French writers. Charcot maintains that there is always or nearly always some hereditary taint. The German writers do not take this view, and in my own cases there is no evidence that heredity plays any important part ; certainly in none of my eases was there discoverable any serious neurosis or psychosis in the family. The patients, however, were many of them of a neurotic temperament, but perhaps no more so than many other persons who have not been victims of major hysteria. The exciting cause is the injury. In my experience an electrical shock has a particularly powerful effect in producing traumatic hysteria. Three of my sixteen cases developed hysteria in this way. In one ease, however, the patient did not actually get a shock, but only thought that he got one. The nature of the injury does not seem to be of nearly as much im- portance as the fact that the surrounding circumstances excite intense fear. However, it seems likely that blows upon the head are rather more apt to produce hysteria than contusions or injuries of other parts. I do not know of any case in which a person got hysteria if he was injm-ed while intoxicated or asleep. Direct injmy to a nerve is said by Thorburn to be a potent cause of producing hysteria. The climate and season of the year seem to have no special effect upon the disorder, other than that hysteria is more prevalent in temperate chmates and in large and popu- lous cities. The person's state of mind previous to the injury prepares the way for the development of the neurosis. Thus if a person travels with a mind full of alarm and agitation over some possible calamity, the hysteria would be more likely to develop should such an accident actually occur. This is weU illustrated in the case of a patient of mine who had read of the killing of a man by an electric wire. A few days after he was walking along the street, when suddenly a dead wire fell and struck him on the head. The blow was not very severe, nor was there any electrical current passing through the wire, but the man fell unconscious, and when he was aroused he was found to have a typical hysterical hemiplegia with hemiansesthesia. The fact may well be borne in mind that traumatic hysteria may be produced by surgical operations, and especially, in my experience, by minor operations conducted under cocaine rather than under ether. Operations upon the nose and throat and minor operations upon the uterus are not infrequently followed by nervous and hysterical disorders. Symptoms. — The disease develops in different ways ; it may be either gradual or sudden. In some cases the ]3atient receives an injury or fright, and at once becomes excessively excited, and perhaps even deliri- ous for a few hours. Upon becoming quiet it is noticed that one half of the body is paralyzed, and upon further examination it is found that there is a loss of sensibility upon this same side, and that all the classical sjrmp- toms of a hj^sterical hemiplegia have developed. In other cases the patient after a fright or shock falls down in a state of unconsciousness or passes into an hysterical attack, during which violent convulsive move- ments are made. After emerging from this attack he is found to be suffering from some form of hysterical paralysis. In still other cases a PLATE IV. ■i^^'''^'»,C" * "-^ "'^ HYSTERICAL HEMIPLEGIA, showing the peculiar dragging of the foot. THE TRAUMATIC NEUROSES. 339 person receives an injury, becomes somewhat stunned or prostrated, but recovers and goes home or resumes liis Avork. In the course of a few days he notices that he suffers from headaches and sleeplessness ; that he is irritable and easily excited, and is entirely unlike himself. After a few weeks he perhaps gives up his work, and during this time he has attacks of swooning or of cataleptic or convulsive character. These attacks are alarming, but they pass away and he continues to be simply suffering from a nervous irrital)ility and depression, with more or less vague pains about the head and Ijack. The picture, in other words, is much like that of a traumatic neurosis. In the course, however, of a few weeks, or per- haps even months, there develop symptoms of a much more severe char- acter. The patient is found to lose the power of one side of the body, or perhaps to be gradually becoming paraplegic ; and associated with this condition of paralysis are found disorders of sensation and other sjonp- tonis of the hysterical condition. In a tAT3ical case of traumatic hys- teria the symptoms may be described very much as follows : The patient is usually a man of middle age. He suffers from a paralysis of the arm and leg on the same side — in other words, a hemiplegia. This paral- ysis affects most the arm and less the leg, while the face itself is not in- volved. The paralysis is never absolute. The patient can move the arm a little and can draw up the leg and often can walk about, though Tvdth some difficulty. The hemiplegia is of a flaccid type — that is to say, there is none of the rigidity associated with hemiplegia due to organic lesion. The reflexes at the knee are, if anything, diminished, though sometimes slightly exaggerated, but there is no ankle-clonus. The gait of the pa- tient with this hysterical hemiplegia is characteristic : instead of swinging the foot round in a semicircle as in organic hemiplegia, the paralyzed foot is dragged in a nearly straight line, the toe scraping the floor. (See PI. II.) The absence of paralysis of the face is characteristic. Sometimes there is said to be an apparent facial paralysis, which is, however, really due to facial spasm. The tongue when protruded goes out straight, as a rule, but sometimes it turns over toward the paralyzed side, owing to spasms of the muscles of that side. This lingual spasm is an interesting char- acteristic of traumatic hysteria. The patient has sometimes — in fact, in the majority of cases — along with this hemiplegia a tremor of the arms and to a less extent of the lower limbs and facial muscles. This tremor is more marked on the paralyzed side. It has the characteristics gener- ally of the tremor of a multiple sclerosis, though it is often even more exaggerated and jerk3\ The tremor ceases when the hand is quiet ; it begins when voluntary motion is made, and it becomes A-ery exaggerated in attempts to place the finger upon some definite part of the body or to use some instrument in a definite muscular action. This tremor ceases during sleep. It affects sometimes the tongue, producing^ a peculiar nervous articulation, not exactly like that of multiple sclerosis, but more like that of an excessively excit^ed man. There is no nystagmus, nor is there usually much tremor of the face, though this may be slightly pres- ent. The tremor as I have described it is often not very much marked, and it may be even practically absent. There is no atrophy of the mus- -cles of the affected side, nor are there any electrical degeneratiA'e reac- tions. Vigouroux at one time stated that there was an increase in the resistance of the paralyzed limb to the electrical current over the limb on the sound side, and this is occasionally observed. The patient is 340 A SYSTEM OF LEGAL MEDICINE. found to suffer not only witli a paralysis on one side of the body, but with an ana?sthesia of the skin upon this side. This cutaneous anaBS- thesia in some instances involves the whole of the paralyzed side of the body from head to foot, stopping sharply, however, and absoluteh", at the middle line. Such extensive aneesthesia is rare. More often the anaesthesia involves the foot and leg up as far as the middle of the thigh, the arm up to near the shoulder, and the side of the head ; in other words, it has what Charcot has called the gauntlet and stocking type. (See Fig. 53.) Fig. 53, showing the different modes of hysterical ansesthesia. The dark spots indicate hysterogenic zones. The an£esthesia may extend, however, to the other side, so that there is a bilateral anaesthesia. This is extremely rare, especially in traumatic cases. The anaesthesia may occui' in zones or patches on the surface of the limbs or the head. These zones or patches do not correspond mth the distri- bution of any nerves, and in this respect they are characteristic of a hysterical condition. The anesthesia much more frequently affects the arm, leg, and face together ; next in frequency the arm and leg ; then come the ii-regular tyj)es that I have spoken of. In some instances the anesthesia may be crossed — that is to say, there is anesthesia on one side of the face and on the opposite side of the body. The anesthesia as well as the paralysis is usually found to be on the same side as the injurj^, particularly if the injury is a blow on the head. This fact is often an important and practical one. A blow upon the right side of the head, for example, if it produces a hemiplegia from organic disease, would produce a hemiplegia on the left side of the body ; but if it pro- duces hemiplegia of a functional or hysterical character tins will occur on the same side as the external lesion. Regarding the character of the cutaneous anesthesia I have made a number of observations.* I have found that the touch sense was the least affected, while the reaction to painful sensations was most frequently and 1890. "A Study of the Anaesthesias of Hysteria," Amer, Jour. Med. Sciences, October, THE TRAUMA TIC NEUROSES. ;54i inost extensively abolished. Between these two eanie the teinperatnre iuuesthesia. I fouiul also that there was very rarely any ana'sthesia of the nius(nilar sense or artienlar sense exeept when the paralysis was very profonnd. This lattt'r eonelusion is at varianee with the theories of Dr. Bastian and with some of the data wliieh he has eolleeted. However, I "believe it will be found that in moderate grades of hysterical hemiplegia there is no great degree of ataxia or disturbance of muscle or articular siMisation ; (certainly this is the experieuce in a numl)er of very carefully ol)served eases of my own. When, however, the paralysis is absolnte, there is undoul)tedly^ in most cases, if nc^t all, nuiscular auajsthesia also. (fSee Figs. 54, 55, 5G, and 57.) Fig. 54. Fig. .5.5. Fig. 56. Figs. .54 to 57 show bv contrast the distribution of anaesthesia in lesions of the cauda equina (Figs. .54, .55, 50) and in myelitis Fig. 57, on next page), as compared with that in hys- teria (Fig. 53). Besides the cutaneous anaesthesia there is an anaesthesia of the special senses — of sight, hearing, taste, and smell — upou the affected side. There may be a very great dimming of the vision of the eye of the affected side, but as a rule the disturbance consists in a concentric limitaticm of the visual field. With this phenomenon there is at times a change in the color sense and in the color fields. In some cases the only trouble consists in a disorder of the color fields, and in some cases there is an actual loss of color sense altogether. I have observed this in two cases. Drs. Mitchell and De Schweinitz, who have made a study of this subject, failed to find it in a series of twenty-five cases, not, however, of traumatic ■character.* The green field is relatively more and more often contracted * Complete studies of tliis subject liave been made by Pausiea {Ocular Manifesta- tions of Hjistcria, Paris, 1802), by Wildbvand and Sanger, by FraMikel, Hopevart, and ■To))()laHski, by Willielm Koiiig, and very recently l)y Mitchell and Pe Schweinitz (.lonrnal of Kcrroits and Mental Disrase, January, 1894), wlio give a full bibliography. These latter authors give specific directions for testing the concentric limitation of the visual field. Tlieir tests were nnide by means of the perinuner. The test-objects were white and colored cards 1 1 cm. in diameter. The patient is placed in a good liglit, and the test must be made in several different ways. First, for near objects : in this case the test-card is moved from without inward, and the point noted where it is 342 A SYSTEM OF LEGAL MEDICINE. than tlie others. (See Figs. 58 and 59.) Reversal in the normal sequence- of the colors, so that red is the largest field, is usually present, the normal order being bine, red, and green. The field of vision is contracted in both eyes, but more on the affected side. The contraction is always more or less concentric, and does not present the characters of a hemianopsia — that is to say, the visual field is con- tracted at all points of its circumfer- ence, and there is no half -blindness, either horizontal or vertical. To this rule Mitchell and De Schweinitz have reported an apparent exception {loc. cit.). The hearing on the affected side is sometimes much impaired, and is almost uniformly affected in some way or other. The most frequent disturbance is a diminution of hear- ing or absolute deafness to bone conduction, while hearing is fairly good to aerial conduction. Loss of the power of hearing high notes and very low notes is also a frequently observed phenomenon. The deaf- ness to high notes occurs almost without exception, as tested by a Galton whistle. Deafness to low notes I have found in only two or three cases. In these the patients were unable to hear a note made by the bass strmg of a viol giving vibrations of about 34 or 68 per sec- ond. The senses of smell and of taste are abolished on the affected side. The most striking symptoms of hysteria major are those that I have just described — paralysis and anaes- thesia. The distribution of these symptoms, however, is not always hemiplegic. Sometimes a patient suffers from simply a paral}' sis of one arm or of a leg, or of both legs. An hysterical paralvsis of an arm is the more common. Hj'sterical paraplegia is relatively rare, particularly the cases which can lie spoken of as in a true sense hysterical, that is, of cerebral origin. When the patient suf- fers from an In^sterical arm-palsy he has, along with the palsy, which is flaccid in tNqDe, anaesthesias of the skin and perhaps of the muscles, and he has at the same time some of the an9ethesia,s of the visual, auditory, Fig. 57. Distribution of anaesthesia in a case of myelitis. first recognized. Then it is to be moved from within outward and the point again noted. It is well to repeat this procedure once or twice. If there is ground for suspecting simulation the test must then be repeated with the test-object held some five or six feet away, and the results compared with those obtained at a nearer dis- tance. The accompanying chart represents the physiological limits of the field for form and for blue, red, and green. (Fig. 58, p. 343, also Fig. 59.) THE TRAUMATIC NEUROSES, 343 and other special senses. If a person suffers from hysterical paraplegia of a t3q)e that is truly liysterical, lie will, I am convinced, have along with this paraplegia some disturlj- ance of cutaneous sensation of the affected parts. There will be also some evidences of disturbance of the special senses, and often there occur certain disorders of motor cranial nerves, more especially a hngual spasm. In hysterical para})legia there is some exaggeration, as a I'ule, of knee-jerks, and after a long period of time thei'e may be contractures. There are, however, in the early stages no muscular atrophies and no changes to the electrical currents. There may be a slight disturbance of the bhidder for a time, but no persist- ent impairment of its f unction . I am convinced, with Dr. Bastian,that as we become more familiar with the char- acters of these paraplegias we shall be less inclined to consider them all as of cerebral or hysterical origin, but rather to place some among the functional paralyses of spinal character. Fig. 58. Diagram of the normal field of vision of the riglit eye for hlue, red, and green. The outer continuous line indicates the limit of the form field ; the broken lines, the limits of the color fields. (De Schwei- nitz and Mitchell.) Fig. 59. Diagram of the normal field of vision of left eye for form blue, red, and green. (Landolt.) Besides the symptoms of heitiiplegia and sensory disorders there are other troubles from which these patients suffer. As a ride, the patient is very 344 ^ SYSTEM OF LEGAL MEEICIXE. mucli depressed mentally and discouraged about himself. (See PL T ) He suffers a great deal from pains in the back and limbs and hip, and is apt to be of a very complaining habit. He is usually emotional, and ciies easily. He is persistent in his expressions of a desire to get well, and will usually carry out very faithfully the directions given to him by his physician. He has at times hysterical attacks or crises. In men these attacks seem to take more often the character of simple comatose or le- thargic stages, the patient passing off for a few minutes or hours, or even days, into a state of what resembles hypnotic sleep or lethargy ; at other times the patients have emotional and almost maniacal attacks or decided convulsive seizures, and more rarely go thi-ough the characteristic hys- tero-epileptic phenomena. I have never, however, in this country, seen the typical hystero-epileptic attacks develop in males with hysteria of traumatic origin. Again, the patients may suffer from violent and obsti- nate attacks of vomiting. Nearly all the cm-ious and weird manifes- tations of hysteria may be exhibited by these patients — the cutaneous eruptions, the edematous swellings, the anuria, the visceral crises, the palpitations, the anginal attacks, and so on. Sometimes there may be attacks of hysterical mutism. It is not necessary for me to go into de- tails of this character, because the symptoms are those which will be found described under the head of major hysteria in special treatises. I have found in my experience that in young women the interpar- oxysmal marks of hysteria, such as the auEesthesias and paralyses, are less common, while contractures and tremors of various kinds and pain- ful neuralgic disorders are more frequently observed. In traumatic hys- teria in women also crises of various kinds, more particularly convulsive attacks, are much more frequent. I believe that I cannot better supple- ment a description of traumatic hysteria than by giving the history of certain typical cases of this disorder. The first is that of a man who illustrated in a classical way the ordinary symptoms of traumatic hysteri- cal hemiplegia. The second case illustrates a somewhat irregular type of this disorder, occurring also in a man. The third case illustrates the de- velopment of traumatic hysteria in a young woman. Case I. Traumatic Hysteria. — B. N., aged fifty ; married ; Moravian by birth ; clerk. Mr. N. states that he has always been well, is of temperate habits, has had no venereal disease, has a family of five childi'cn, all healthy. He was walking along the street September, 1889, at the time of the great excitement about street currents, when he saw a mre from an electric-light pole falling toward him. The wii'e struck him across the head, making a welt on his derby hat ; he seized it in his right hand. He does not remember any more until he came to in New York Hospital. He is said to have faUen down, then to have been helped up, and to have walked with some assistance. When struck, he saw a bright light, but felt no peculiar sensations of any kind. When admitted to the hospital he was conscious and soon able to talk, losing his amnesia except, as he says, of the events just after the blow. There was a black stain on his right hand, but no burn. His right arm and hand and leg were paralyzed, the leg almost completely, H < Q. THE TI! ALMA TIC X EL ROSES. 347 SO that he eoiihl not walk. Tlie face or tono-ne was not involved. There was complete hemianu'stliesia. of the right side of tlie Ixxly. The l)ladder was normal. The mental condition t^'ood, tliou;^h lie did not sleep well for a few uig'hts. The abdominal and tiioi-acic viscera seemed to be normal. Throng'h the kindness of tlu^ visit inij;'-])hysiciiin, Dr. William (1. Thomp- son, and the house physician, Dr. C-obb, I was enabled to make an exam- ination of the patient, September 24th. He was then able to walk slowly iind to use his right arm faiiiy well. He seemed to be an intelligent man, somewhat emotional, but anxious to tell the truth about his symp- toms and to get well and back to his work. His mind was clear, and he suffered from no emotional depression or ciises. He was sleeping well. His pulse was quite rapid (120) under iwy examination, l)ut it had been normal, as were the temperature and respiration. The face showed no paralysis, the tongue was protruded straight, and the pharyngeal arch was even. The right arm was weak, but he could execute all movements with it except raising- it directly over his head. Dynamometer : right hand, 25 ; left hand, 40. There was a tremor in the arm and hand and occasionally in the leg;. This tremor was rapid, but of rather large excursion, and increased on voluntary movement, or on directing- attention to it. It was an "intention" and "attention" tremor. It did not affect the face or tongue. Si3eech was clear and deg- lutition normal. The leg was much more paretic than the arm. The foot and toes could barely be moved, the leg* could be flexed and extended but partially. The tendon reflexes of arm and leg were present, but not exaggerated. The skin reflexes were well marked. There was anees- thesia in varying degree over the right side of the body. It was most marked in the lower limb, where it extended diffusely up to about Pou- part's ligament in front and the gluteal fold behind. In the arm the anaesthesia was more marked over the area of the ulnar, but it was pres- ent in a degree over tlie whole extremity. Around the shoulder and neck it became less. It was present over the right half of the face, including the tongue, but Avas less marked here than on the extremities. The anass- tliesia was most marked for cold sensations, well marked for pain, and less marked for tactile sense. There was no muscular aufpsthesia or loss of coordination as tested by weights and by touching the nose and postur- ing the limbs. The special senses showed peculiar conditions. The pupils were nor- mal, even, and reacted to light and accommodation. There was no color- blindness. The man was presbyopic, but since his admission he had been unable to read well. (He had broken his glasses.) His i-iglit eye showed decided limitation of visual field, the left very much less, though some was present. No difference in \dsual acuteness Avas noted, and no hemianopsia. The right ear showed hearing equally acute to the tick of a watch or the voice or tuning-fork, but absolutely deaf to l)one conduction. A large tuning-fork vibrating on the mastoid was not heard ; and vibrating on the teeth was heard only by left ear. Tested by Galton's Avhistle, the left ear showed a decided loss of hearing of high notes ; the right still more. I had never met befcn-e a person so deaf to so great a range of the upper notes, though it is not very uncommon to find slight degrees of this deafness in the aged. The man had cvidimtly a limitation of the .auditory field eompanible to that of the visual field. 348 ^ SYSTEM OF LEGAL MEDICINE. There was an almost complete loss of smell in the right nostril, and a^ complete loss of taste on the right side of the tongue. There was also absence of pharyngeal reflex when the finger was thrust into the back of the throat. There were no manifest secretory or trophic disturbances of the af- fected side. The man complained of very little pain. The electrical re- actions were not taken. We have here a case of traumatic hysteria of the tj^e described \>j Charcot, G-uinon, and the French wiiters. The points are so marked and characteristic that a discussion as to diagnosis would be supereroga- tory. We have the (1) hemiplegia not involving the face ; (2) the anaes- thesia distributed in the " gauntlet" sha];)e, i.e., not follo^\dng nerve tracts but involving mainly the limbs, and covering them like a stocking or glove ; (3) we have the peculiar limitation of visual field (4) and auditory field, the bone-deafness, (5) the ageusia and anosmia, and (6) pharyngeal aneesthesia. Three years after this accident, the patient was much improved but far from well. Case in litigation and not settled. The auditory phenomena are particularly interesting, as they have not been investigated mth as much care as the visual, and are in my experience rarer. The loss of smell on the right side is confii-matory of the view of a functional hemiplegia ; for in organic hemiplegia from hem- orrhages, etc., it is sometimes on the opposite side to the paralysis. It has also been claimed that the olefactor}^ nerves do not decussate, and hence that hysterical hemiageusia is only apparent and due to trigeminal anesthesia. This would not explain the present case. For the trigemi- nal anaesthesia was very slight and the ageusia almost complete. Case II. Trcmmatic Hysteria with Violent Tremor. — Mr. X., aged fifty-four ; of American bu*th and parentage ; married ; business man. The family his- tory is good in every way so far as any details can be obtained. The patient himself had always been an active business man, travehng a good deal. There is no history of syphilis or alcoholic excesses ; he has, how- ever, been somewhat excessive in sexual indulgence. He had never suf- ered from any serious disease or injiu-y, and was perfectly well at the time of his accident. He was riding on a horse-car when this occurred. There was a collision ; his car was suddenly stopped, and he was thrown violently against another person, being struck on the side of the head. He was not knocked down, but was very much confused. He went home^ however, being at the time somewhat excited and nervous over the acci- dent, and in a few hours passed into a partially comatose state, which lasted for two days. This ended in a violent hysterical outbreak of a maniacal or delirious character. This had subsided in the course of a week, and he was then found to be unable to use the left arm or leg. One month later muscular twitching and tremor began in the left arm. This tremor extended and soon involved the right arm and the muscles of the neck and head. About this time there was found to be also a left hemianaesthesia. He complained all the time of pains in the neck and head while these various phenomena were developed. The pains in the THE TRAUMATIC NEUROSES. 349 head and neck and the tremor were found to be somewhat relieved by pulling on the head, so that his physician constructed for him a jury- must by which pernument supjxjj-t was given, and while wearing this he stated that he felt more comfortable. He was able to walk about, though not without much difficulty. The patient was brought to me by his i>hy- sician. Dr. Gray, for examination while in this condition, some six months after the accident. I found him to be a well-nourished man, not at all anaemic, but having a depressed and distressed look. He walked with a dragging of the foot on the paralyzed side, in a manner that was perfectly typical of hysterical hemiplegia. His face was not involved by either paralysis or spasm. The tongue turned slightly toward the left. The left arm and leg were nearly powerless. He could Ilex, extend, pronate, and supinate the fore- arm and hand, but his upper arm was weaker ; he could only j^artly con- tract the biceps and could barely raise the arm out from his side a few inches. He could not keep the arm up when held. He showed the same general weakness in the leg, though this was relativel}^ less paralyzed. He could stand and drag the leg along ; he could extend and flex the foot ; he could do all movements, though feebly. The paralysis of both arm and leg was of the flaccid type, and there was no rigidity or spasm. The knee-jerks were normal on the left, somewhat exaggerated on the right ; the elbow-jerks the same. The arm was affected with a marked tremor, which was coarse in character, and did not increase with voluntary move- ment, but continued active. On resting the arm the tremor ceased. He could carry a glass of water to his mouth. There was more tremor in the right arm than in the left. There was a very decided antero-pos- terior oscillation or tremor of the head; this was lessened and almost stopped b}^ taking hold of the head with the hands and pulUng upward. There was no notable tremor of the legs. There was some cutaneous anaesthesia on the left side, involving especially the arm, the shoulder, upper part of the trunk, and to a less extent the leg. The face was not involved. There was no ataxia. There was a vasomotor paresis of the left hand and arm, which were reddened and felt colder than the right. There was a slight atrophy of the left arm, the left forearm measui'ing 8i|, the right forearm 9 J inches. The electrical reactions showed a slight lessening of galvanic and faradic irritability. Electric sensibility was lessened in the left arm. The pupils were normal in reaction, and not dilated. Some visual weakness in the left ej^e ; concentric limitation of the visual field ; no re- versal of the color fields, but the green field was very much contracted. The ears showed a loss of hearing to high notes, especially in the left ear, with a lessening of bone conduction in that ear. There was impairment of taste on both sides and a loss of smell on the left side, also an anaesthesia of the nasal mucous membrane, although there was no evidence of anaesthesia of the cutaneous surface of the face. The patient was a nuin of fair intelligence. He was suffeiing a good deal from pain in the head and mental depression, and from the incon- venience of his tremor and paralysis. He had no con\'ulsive attacks or crises of any kind after the first week following the accident. The case was settled out of court and lost sight of by me. 350 ^ SYSTEM OF LEGAL MEDICINE. Case III. Traumatic Hysteria in a Woman-cataleptic. — K. C, female; aged tweuty-two, single ; nativity and parentage, American ; occupation, sales- woman. Family liistoiy absolutely negative, parents and brothers and .sisters were all healthy. The patient used to be a well, strong, and healthy girl, said not to have been of a nervous temperament. She had done her work regularly as saleswoman for several years, and was intelligent and competent. On December 11, 1892, she was struck on the top of her head by an iron instrument which fell from a shelf upon, her. It knocked her down and she was made senseless, and shortly after went into convulsions the character of which I do not know. She was revived and walked home two hours later. There was a cut found upon the head when she was examined by the physician that day. She went to bed and slept that night, and stayed at home for the next three days, suffering from headache and loss of appetite. Then she went to work, but suffered continually from headache, loss of appetite, and a feeling of weariness and exhaustion. At times she had to go home from her work before the day was over. She menstruated regularly. She gradually lost flesh, but kept up her work until the early part of March, 1893, three months after the accident. She then had an at- tack of convulsions again, without any known cause. There had been meanwhile no attempts at litigation on her part. The convulsions con- tinued daily after this time ; she would have them several times in the course of the twenty-four hours. She woidd fall back on the bed appar- ently unconscious and become perfectly rigid, then she would go through various coordinated but irregular convulsive movements. She sometimes did not lose consciousness, so she said ; at other times she did. I had an opportunity of examining her in one of these states of unconsciousness with rigidity, about a month after the convulsions began. I made the diagnosis of traumatic hysteria, prescribed for her some valerianate of zinc with tonics, and advised, if possible, a removal from home. After my visit the attacks became somewhat lighter and consisted simply of f ainting-spells, during which she became unconscious and somewhat rigid for about half an hour. She would have several of these weekly. Dur- ing the next six months these attacks grew still lighter and more infre- quent. The patient gained some strength, though she was still weak and pale, and in aU respects unlike herself. Examined by me at this time, nearly nine months after the original injury, I found that she had no paralyses, no tremor — in fact, no special motor-disturbance except a general weakness. There was some exaggeration of the knee-jerks, how- ever, and of the elbow-jerks. There was no cutaneous or muscular an- assthesia. Examination showed a very decided concentric limitation of the visual fields. This was almost equally marked for all colors in the right eye, but only a limitation by the rule for all colors in the left eye. There was no loss of color sense and no reversal of the blue and red fields in either eye. The vision of the right eye was somewhat weaker, apart from limitation of the field, and she had decided anaesthesia of the right nostril both to ammonia and to odors. There was also some pharyngeal anaesthesia and some disturbance of taste on the right side of the tongue, so that bitter was tasted as salt. The hearing in both ears THE TRAUMATIC NEUROSES. ;Jol was good as to range and conduction and acuity. The patient has con- tinued to improve, and I have since lost sight of her. Prognosis. — It is difficult to make a general statement with regard to the prognosis of traumatic hysteria. There are cases which are well in a few weeks from the onset of the symptoms; there are others in which the disease lasts for three or four years, and I have known cases in which the duration was very much longer. Charcot gives a rather unfavoraljle prognosis for cases of hysteria major where the symptoms have become fixed, whether this be of traumatic or other origin. Thorbm-n speaks more hopefully of such cases, and believes that if they are treated promptly and if there is no complicating element of physical injury or litigation, patients ought to get well in a few months at least. My own experience is that in traumatic cases the patients may all be said in a general way to be curable, but that even under good conditions they may suffer for several years aud are liable to a relapse after recovery has taken place. There are many cases, however, in which complete recovery has taken place within a few months. There is no doubt that the fact of a Htiga- tion and the prospect of damages influence markedly the prognosis, and few patients, even though they be perfectly honest, get well while the anxiety of a trial weighs upon them. The coexistence of a physical in- jury, such as a severe sprain or an injury to a nerve or a bad contusion of the head, makes the prognosis less favorable. The prognosis is less favorable in middle-aged males than in young men, and it is usually more favorable in women than in men. The presence of chronic alcoholism, of sexual abuse, of a decided neurotic tendency, all make the prognosis less favorable. The marked fluctuation in the symptoms, such as trans- ference of the aucPsthesia or partial disa^^pearance of it under metals, makes the prognosis more favorable. Finally, it must be remembered that severe types of hysteria major appear in rare instances to be asso- ciated with the development of organic changes in the nervous centers. Pathology. — The prevalent view with regard to the nature of major hysteria is that which has been so carefully elaborated by Charcot. This is to the effect that through the influence of the nervous shock the patient becomes to a certain extent self -hypnotized, and as a result of this has paralysis which is strictly comparable with that artificially produced by hypnotism ; in other words, traumatic hysteria major is a condition of auto-suggestion in wliicli the antesthesia, paralysis, tremors, contraction of the visual field, aud other symptoms are the result of a violent excite- ment of the imagination, with an accompaupug loss of volitional aud inhibitory power. Reduced to non-teclinical language, this theory is that traumatic hysteria is all a fancy. Such view is entirely insufficient, in my opinion, to explain the symptomatology of the disease. No person who had not received some pi-evious suggestion could by any exercise of his imagination think himself suffering from loss of smell, taste, vision, hearing, and tactile sense on one side of the body alone, for such complex of symptoms is entu-ely unknown to the laity. There must be, therefore, something more than this postulated in order to explain these curious phenomena. This further element in the theory of the condition is as- sumed by others to be a vascular spasm, it being thought that liy the influence of a nervous shock there can be produced a spasm of certain vascular areas which nourish the posterior parts of the internal capsule 332 ^ SYSTEM OF LEGAL MEDICINE. and perhaps the sensori-motor areas of one side of the brain. Dr. Bas- tian seems to think that the vascular theor}^ is the essential and perhaps the efficient one. For my own part, it seems to me we are at present quite nnable to explain the phenomena of major hysteria with any degree of satisfaction. So far as the pathological anatomy is concerned, we stand upon a firmer ground. It seems almost incredible when one sees these severer types of hysteria that there should not be some organic change under- l^dng it. The fact that there is no such change, however, has been dem- onstrated : first, by the histories of cases in which sudden cure has taken place even when the paralysis and aueesthesia were most complete ; and secondly, post-mortems by Pell, Oppenheim, and others on eases of trau- matic h3^steria have demonstrated that there are no lesions appreciable to the naked eye or through ordinary microscopical research. BIBLIOGRAPHY. 1766. (1) Maty, "Medical Observations." A palsy attended by uncommon symp- toms. A case cited by Erichsen as illustratiug spinal meningitis the result of concussion. 1815. (2) Boyer, "Maladies Cliirui'gicales," vol. iii., p. 135. Two cases of concus- sion with, paraplegia, autopsy showing no lesion. 1816. (3) i?eZZ, /Sir 67*., "Surgical Obsei'vations." Two cases of concussion of spine. 1818. (4) Girarcl, G., "Notes on the Causes and Treatment of Nervous Affections among the Wounded." "Jour. Gen. de. Med. and Chir. et Phar.," Paris, 1818, vol. Ixiii., p. 318; vol. Ixiv., pp. 14, 155. 1818. (5) Brodie, Sir Benjamin, "Pathological and Surgical Observations on Dis- eases of Joints." Hysterical joints. Also "Lectures Illustrative of Certain Local Nervous Affections," 1837, Lecture ii. 1823. (6) Coojjer, ;S7r J., "Dislocations and Fractures," 8voed., p. 526. Two cases of concussion of spine. 1827. (7) Travers, on "Constitutional Invitation." London. Describes shock, and in particular the "erythistic form." 1828. (8) Abercronthie, "Treatise on the Brain and Spinal Cord," p. 375. Cases of concussion of the spine. 1836. (9) Mayo, "Outlines of Pathology." London, 1836. Concussion of spine ending in evidence of organic disease. 1837. (10) Ollivier, " Traite des Maladies de la Moelle Epiniere." Paris, 1837. Col- lects thirteen cases of concussion. 1864. (11) LideU, John, "Injuries of the Spine and Concussion of the Spinal Cord." "Amer. Jour, of Med. Sciences," October, 1864. 1864. (12) Peronne, J. B. E., "Nervous Accidents Consecutive to Wounds." Essay upon the mechanism of their development, 4to, Paris. Thesis. 1866. (13) Erichsen, "Railway and Other Injuries," 2d ed., 1875, 1882. 1866. (14) Mitchell, S. Weir, "Paralysis from Peripheral Irritation." "N. Y. Med. Jour.," 1866, vol. ii., pp. 321, 401. 1866. (15) Clarke, Lockhart, "Transactions of the Pathological Society of London," 1866, vol. x-vii. Case of tabes following injury. Autopsy. 1867. (16) ^M^^^arf?, T/«., "Cases of Injury from Railway Accident." " Lancet," vol. i., p. 389. 1867. (17) Fletcher, J. O., "Medical Aspect of Railways." 1867. (18) penheim, H., "Die Trauvi.'Neui'osen." Hirschwald, Berlin. Also"Neu- rolog. Centralbl.," p. 471. 140) Bremer, L., " Traumatic Neuroses." "Alienist and Nem-ologist." 141) Briins, L., " Kasuistik der Traumat. Neuroses Nerv.-Centi'albl." Case of traumatic hysteria from slight injury. 142) SeeJigmidler, " The Question of the Simulation of Nervous Diseases after Trauma." " Centralbl. fiir Neurologic," No. 20. 143) Dutd, "Gaz. Med.de Paris," November 30th. Traumatic and non-trau- matic hysteria, three cases. 144) Dana, C. L., "Med. Record.," p. 477. Traumatic hysteria from fright. 145) Watson, B. W., "Med. Record," October 18, 1889. Experiments on dogs. 146) Auerhach, X., "Traumatic Hysteria in Man." "Deut. Med. Zeitung," August 26, 1889. Dissertation. 147) Dercnm, "Railway Shock and its Treatment." "Therapeutic Gazette," May-October, 1889. "Remarks on Spinal Injm-ies." "Therapeutic Gazette," May 15, 3 889. 148) Smith, H. H., "Case of Malingering." "Journal of American Med. Asso- ciation," August 10, 1889. 149) Watson, Penrose, "Malingering." "Jour. Amer. Med. Assoc," August, 1889. 150) Jndd, "Malingering." "Jour. Amer. Med. Assoc," February 22d. 151) Wichmann, "Berlin. Klin. Woch.," July 1, 1889. "Malingering." 152) Meyer, M., "Berlin. Klin. Woch.," February 4, 1889. "Neurasthenia caused by Chronic Concussion in Railway Employees." 153) Meyncrt, " Wien. Med. Wochensehr.," June 14th, 20th, 27th. "A Theory of Cause of Traumatic Hysteria." 154) Klev-e, A., "The Traumatic Neuroses," 1889. Berlin Thesis. 155) lienkel, Tal., two cases of traiunatic neuroses. "Inaug. Dissert.," Er- langen, 1889. liiiiLioanAriiY. 557 1889. 1889. 1889. 1889. 1889. 1889. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. 1890. (156 (157 (158 (159 (KiO (IGl (1G2 (1G3 (104 (1G5 (16G (167 (168 (169 (170 (171 (172 (173 (174 (175 (176 (177 (178 (179 1890. (180 1890. (181) 1890. (182 1890. (183 1890. (184) 1890. (185 1890. (186 1890. 1S90. (187 (188 Sclmefer, " Study of Railway Spine." " Berlin. Klin. Woch.," No. 43, 1889. Case oansed by fri<^lit alone. BcTHlKirdt, "Keriiai'lciih(tHiii, G., two cases of local traumatic neuroses and their course. "Therapeutic Monat.," Berlin, 1892. 1892. (233) GiUet de Gravdmonf, "Traumatic Neurasthenia and Ocular Accidents." "Bull. Soe. de Med. Prat, de Paris," 1892, p. 244. 1892. (234) Horwit-, "Neurotic Ct:deraa following,' Trauma." "Med. News," 1892, vol. Ix., p. 432. 1892. (235) Li/nidii, //. .1/., "Traumatic Paralysis Agitans." "Chicago Clinic Review," 1892, vol. i., p. 42. 1892. (236) Mullier, "Observations on Traumatic Neurosis." "Arch. Med. Belg.," 1892, vol. xlii., p. 242. 1892. (237) Bacli, J., "Klinischer Beitrag liber Traumatic Hysteria." 8vo, Breslau, 1892. Thesis. 1892. (238) J3erwcn/», 7!,'., "Ueber Traumatische Neurosen." 8vo, Strassburg, Isted., 1892. Thesis. 1892. (239) Buts, E., "Storungen der Sensibilitiit durch Traumen." 8vo, Wiirzburg, 1892. Thesis. 1892. (240) Bcrnlieim, "Traumatic Neurosis of the Nuehge." "Rev. Med. de I'Est.," 1S92, vol. xxiv., p. 489. 1892. (241) Biii-(iir, " Laryugoscopic Findings in Traimaatic Neuroses." "Berlin. Klin. Woeii.," 1892, vol. xxix., p. 1197. 1892. (242) EiseuJnhr and Belnhard, "Neurolog. Centralbl.," February 15, 1892. Simu- lation. 1892. (243) Oppoilieiiii, "Die Traumatisehe Neurosen." Second edition. Simulation. Special character and symjitoms of traumatic neuroses. "Arch. f. Psj'cli.," vol. XXV., p. 248. Simulation. 1892. (244) Schnlfze, "Deut. Zeitseh. f. Nervenheilk.," vol. i., p. 445. Simulation. 1892. (245) Frennd, C. S., "Ein Ueberlick ueber den gegenwartigen Stand der Frage von den Sogenannten traum. Neuroses." Volkmann's "Vortrage." 1892. (246) Dercum, " Journal of Nervous and Mental Diseases," January. Cases not in litigation. 1892. (247) Nonne, A., "Deut. Med. Woeh.," July 7th. Visual fields, etc. 1892. (248) Schmidt-Bimpler, "Deut. Med. Woeh." Visual fields, etc. 1892. (249) Muchfichcr, "Deut. Med. Woeh.," April 28th. Muscular asthenopia as an objective symptom. 1892. (250) Lanoisteiii, "Deut. Med. Woeh.," April 14th. Chloroform narcosis for simulators. 1892. (251) Bnmpf gives three objective tests : pressure on painful points ; quanti- tative reduction of galvanic irritation ; faradization of nerve-trunk, causing fibrillary contractions. 1892. (252) A"(?»wfn(H, J., "Inter. Klin. Rundschau," August 14th. Case of traumatic hysteria. 1892. (253) Charcot, "Clinique des Mai. du Syst. Nerv.," Tom. i., 1892, pp. 29, 117. Hystero-traumatism. Prognosis. 1892. (254) Benedict, "Ueber Hyperaesthesien der Kopfknoehen (Nahtneuralgien)." "Internat. Klin. Rtrndsehau," No. 1. 1892. (255) Friedman)), upon a lieculiar form of sequel to brain concussion and the vasomotor sjTnptom complex of it. "Arch. f. Psych.," vol. xxiii. ; alssequent careful microsco])ical examinations, it was not considered necessary to examine the brain and spinal cord in the other cases, esj^ecially as nothing of any importance had been observed in these organs in this case. The micro- scopical examinations showed no recognizal)le changes in the tissues or organs of the 1)ody.' " Falls and Other Injuries. — As a result of falls which follow the receipt of a shock l)y the victim, who nuiy be engaged in a high place in repair- ing wii-es or doing- some other work, there may of course be almost any kind of other injury, wljich varies from simple concussion to fracture of the skull or spine ; but these do not concern us except so far as they are the result of an initial shock, the mode of receipt of which is to be determined, as well as whether the contact was due to the victim's care- lessness, or whether he was unnecessarily subjected to danger through the fault of others. In New Yoi-k City and elsewhere there are any number of "dead" wires, which become, by crossing, the conveyers of fatal currents, and these are often responsible for such accidents. Electric Burning. — Cases of another kind are those in which the electric current produces 1)urns of greater or less gravit}'. Xaukevell reports the case of an electric-light trimmer who I'eceived accidentally the full pressure of 2400 volts through his left hand, which held the wire. He was rendered insensible ; his legs were drawTi up to the trunk. This brought his fidl weight on the wire, which then broke and released him. He was taken to the hospital and there recovered con- sciousness, and, though excited, gave an account of the accident. The thumb and forefinger were black and charred, and an eschar was perceived which extended on the dorsum of the hand to the end of the idna, the traict being burned to .the l.)one. The burned parts were insensil)le, but there was intense pain in parts not burned. On removal to bed four toes of the left foot wei'e found burned on the palmar surface, each eschar being about the size of a threepenny piece. There was no mark on the boot. He recovered in the course of a few weeks. The following fatal case of burning, which was carefully ol)served by Dr. Galvin at the Boston City Hospital, is cited : "Electric shock. Fall from pole. Severe burns from electric-light wire. Sloughing of burns, gi-adual failure, and death. " Peter K., nineteen, single, born in Ireland, a linenum. Some alcohol ; denies syphilis. At 2 p.m. on Novend)er 17, 1886, while on a. pole trim- ining an electric light, was severely l)urned, arul fell about twenty feet. Has no recollection of the fall, or how he struck. Considerable shock. Well developed and nourished. Kight wrist burned su])erficially over a space about three inches each wav. Eight thenar eminence burned through 372 ^ SYSTEM OF LEGAL MEDTCLXE. to the muscles, and adductor pollicis laid bare over a space the size of a quarter of a doUar. Middle fiiiger bm-iied to the bone over a space about two inches long, beginning at tip of finger, and on the back of it. Third finger burned over a space about one inch long on the back. Little finger bui-ned the same as the thii-d. Two middle toes on right foot bui-ned a little. Poidtices to burns. Two wounds of forehead over right eye. each about thi-ee quarters of an inch long, and one of them just over the border of the orlut. Large subconjunctival hemoiThage in left eye. Both wounds stitched with catgut, and sealed up with absorbent cotton and compound tinctui-e of benzoin, after being powdered with iodoform. Brandy, ■'. xxv, and Magendie's solution, "^'L v. subcutaneously ; heaters. Xovemlier 19th. On dangerous hst. Poultice has made burns much less paiufid. Little finger of left hand, which had a brass ring on it, was slightly burned underneath the ring. November 22d. Little finger of left hand has turned completely black. Sloughs on right hand are deeper, and are sep- arating out. Ai-m swelled to elbow. To-night he feels miserably, and says he felt a repetition of the shock of the electricity at four o'clock this afternoon, the time of the accident, or very near it. Still on the danger- ous hst. November 25th. Has been delu-ious for some days. Pulse and temi)erature up. Very sick to-day, and failing fast. This afternoon was constantly muttering to himself. Pulse getting weaker and weaker. Takes brandy, a teaspoonful at a time. Sloughs on right hand very deep and foul-smelling. Little finger of left, hand entirely dead. Died at 4.45 P.M." The Ijiuns are chiefly about the hands, and depend in severity ^"ery much upon the di-yness of the skin : a moist skin conducting more freely, though there are cases where the ciu'rent is so sti'ong and the contact so perfect imder aU conditions that the ine^'itable result is a liad Imrn or series of burns. These are deep and do not heal quickly, are attended by sloughing, but not necessarily by much surgical shock. Many of the burns are severe as the victim is unable to let go or because he is entangled with wn-es so that the contact is prolonged. Sometimes an- SB.sthesia and paralysis of the forearm or arm follows the receipt of such a shock. Medical Electricitj'. — ^Accidents in connection ^ith the medical use of electi-icity are rare, and arise from the incautious application of cur- rents of high tension to the head, especially wheu the subject is a person of advanced age, and wheu there is latent cerebral disease. The too early use of electiical cuiTents after cerebral hemorrhage, or when in- flammation of the nervous stiiictures is concerned, is prone to retard the cure or precipitate fi'esh trouble. In certain peripheral parah'ses ex- cessive electrical stimulation may do much harm, but in such cases what the electiical reactions were before treatment must be determined, and the nature of the jjarticular disease settled. Vertigo and transitory losses of consciousness have been, obseiwed by the wi-iters as sequell^e of cereljral distiu'bance due to galvanic currents of high potentiality. Static electiicity may, through a careless use of Le^'den jars and con- nections, produce a shock of considerable violence ; and a case is known to one of us where the transmission of a six-inch spark through the head produced a temporaiy unconsciousness, and gi-eat subsequent weakness. Induced ciuTents from ordinaiy medical apparatus are not dangerous. EFFECTS OF ELECTRIC CURRENTS. 373 Late Legal Decisions — Some recent medico-legal cases are cited in illustration of the issues that may arise. ■ An interesting case is that of the !S<)utluvest('rn Telegraph and Telq^hoiie Coiiipan/j vs. Eobinson, 2 U. 8. App. 205, in which it was decided that though the injury was inflicted in a manner that the telephone company coukl not prevent, they were liahle. On the aft(^rnoon of October 29, 1889, J. B. Rol^inson was traveling- on horsebac'k on the Dallas and McKinney Highway, Texas, during a heavy tliund(ir-storm, and came in contact wdth one of the telephone company's wires, whicli had fallen and was suspended within a few feet from the ground, and, the wire being heavily charged, he was knocked from his horse and serionsty injured. The jury returned a verdict for $2500, which the United States Circuit Com-t of Appeals for the Fifth Cii'cuit affirmed. The telephone company claimed that the electricit}'^ by which the injury was caused was produced by the liea^y thunder-storm w^hich was raging at the tune. In answer to this the court said: "If the electric fluid with which the ware of the telephone company was charged at the time was an element, or the main element, in the production of the injuries to the defendant in error, still it is clear that the displaced wire furnished the means of the communication of the dangerous force w^hich resulted in the injury to him." An ordinary and clear case of negligence is the case of Clements vs. Lonisiann Mectric Lif/ltf Co., 44 La. Ann. 692. Joseph Clements, who was a tinsmith, was killed on October 4, 1890, by a current from the wires of the Louisiana Electric Light Company, while repairing the roof of a gal- lery in New Orleans. The wires were fastened to a "house" on the gal- lery. They were insulated and appeared to be safe. While cleaning the gutter of the roof he came in contact with two wires and w^as immedi- ately killed. After the accident the insulation on the "s\di'es W' as discovered to be much worn by exposure. This action was brought by the parents of Clements for damages, and the jury awarded them $5000. The Su- preme Court of Louisiana affirmed the judgment, holding that the de- fendants were neghgent in not properly insulatiug the wii"es, but regarded the verdict as excessive, and reduced it to $2000. An important case is that of Burt vs. Douglas Connty Street-Baihcai/, 83 Wis. 229, where suit was brought by Burt, who received a shock in the manner below stated. The defense was contributory neghgence, which, however, was not entertained. The defeudants operate a street- railway in Superior City, Wis. On December 23, 1890, they ran two cars attached together. Each car was built with a platform at each end, guarded by a dash-board, with an iron handle attached. The plaintiit' got upon the first of these cars, but, finding it cold, attempted to go to the other, where there Avas a fire, w'hile the cars were mo^dng, and took hold of the iron handle on each car to step from one car to the other. The wires attached to the cars were not properl}- insulated, and the elec- tricity escaped, the handles becoming heavily charged with it, unknown to plaintiff, and when he took hold of them he received a severe shock and was badly injm^ed, being dragged a considerable distance by the ears, because he was unable to loosen Ids hold of the handles. He brought suit against the railway company for damages and received a verdict f or $1500, which the Supreme Court of Wisconsin affirmed, holding that the -company was chargeable with notice of the defective condition of theii- ap- 374 ^ SYSTEM OF LEGAL MEDICIXE. paratus, and tliat it was not negligence for the plaintiff to pass fi'om one car to the other while in motion. In the case of the Colorado EJedric Co. vs. Luliders, 11 Colo. 505, the action was defeated on the score that the person was injm-ed at a time when he should not have been working at the wii-es and had been so forbidden to do ; but a verdict for the defendant was reversed on eiTor. Charles Lubbers was employed by the Colorado Electric Company as a carpenter to assist in taking care of its light-towers. At 3.30 o'clock in the afternoon of December 17, 1881, he was sent by the superintendent to remove a lamp and connect the wires with the cu'cuit. The usual time for tui-ning on the cui'rent at that time was from 4.30 to 4.45 o'clock. This was outside of his duties and he was not experienced in the work. While connecting the wii-es after remo^dng the lamp the current was turned on and he was shocked and thi'own to the ground and seriously injui-ed. Lubbers sued the company for damages and received a ver- dict. On appeal the Supreme Court of Colorado held that the question of contributory negligence, which was the onl}^ defense urged, was a matter of fact for the jiuy. But the Trial Court admitted, under objec- tion, evidence that after the accident the company put up notices in its works warning all employees to quit work at four o'clock and not to con- tinue mthout notifying the officers. The coui't held that this was error, and on this ground reversed the judgment. A case resembhng the last, in the question of the element of time, was that of Kraafz vs. Brush Electric Light Co., 82 Mich. 457. This was an action for damages caused by negligence brought by Almeron Ki-aatz against the Brush Electric Light Company, by whom he was emploj^ed as a trimmer. On August 19, 1886, at nhie o'clock in the morning, he was trimming lamps on an electric tower in Detroit, when he received a shock and was seriously injured by the contact of a day-'O'ii'e wliich was in operation with the wire upon which he was working, which was " dead " at the time. There was a verdict for the plaintiif , which was affirmed by the Supreme Com-t, reciting the above facts. One of the gi'ounds of defense was that the injm-ies had been caused by a stroke of jDaralysis, but tills being a matter for the jury the coiu't refused to go into it, the jury ha\'iug decided the question. The defense of trespassing was made in the case of Sullivan vs. Boston & A. R. R. Co., 156 Mass. 378. Daniel SuUivan and another boy were playing ball near a coal-shed of the defendant, on Lehigh Street, Boston. The baU was batted and fell on the coal-shed, and Sullivan went uj) and recovered the ball. He then came into contact with two naked copper wii'es on the roof, which were used by the defendant to conduct electricity, and received injuries resulting in his death. Charles Sullivan, as ad- ministrator, then brought tliis action against the railroad company for damages for his death, and on the trial the court ordered judgment for the defendant. The Supreme Judicial Court of Massachusetts, on appeal, affirmed the judgment on the gTOund that the wire was a lawful apj^a- ratus, and not a trap, and that decedent, if not a trespasser, was only a licensee, and that therefore the company was not liable. A case in which the injured man was hurt by the \nves of another company, which approximated those he was repairing, is that of the Au- gusta Raihvay Co. vs. Andrews, 89 Ga. 653, in which the defense of tres- EFFECTS OF ELECTIilC CURIiENT,'^. 375 passing' was advanced. Andrews was employed by a telephone company in Aug'usta, Ga., to put uj) wires. On the same poles on wliich these were to be jilaeed were wires of tlie Aiif2:usta Fii-e Department and tlie Augusta Railway Company. While attemjjting to place tlie teleijlione- wire over the lire-alanu wii-e he received a shock which threw him to the ground and seriously injured liijii. He brought suit against the railway comj>any for damages, charging negligence in the opei-ation of their "feed- wire" in allowing it to come into contact with the fire-alarm wire at tlie intersection of two streets, and that the contact of the two wires produced the current which caused his injuries. The verdict was for the plaintiff, but on a|)peal the Supreme Court of Georgia reversed the judgment, holding that the railroad company was under no duty to protect him, that lie had not l)eeii granted x>ei'itiissioii to climb the poles and thus became .a trespasser, and that therefore he could not recover. Ill the case of Piedmont EUetylc IUumu\(dlu'cs for personal injuries wliicli it is claimed were the result of the defendant's negligence. The greater number of these actions are brought against common-carrier cori^orations or the o'UTiers or occupants of i)remises upon Avhicli the accident occurred. Wh:^n it is remembered that probably half the jury cases tried in the courts of the State of New York alone, in any one year, are actions for personal inju- ries resulting from alleged negligence, and that in almost aR such ac- tions one or more medical experts are called to testify in regard to the plaintiff's injuries, it is apparent what an important part medical testimony must play in this large field of litigation. Medical experts in these cases are generally called to testify as to the probable effect of wounds and injmies in respect to their duration, extent, and residt upon the general health or capacity for mental or pliysi<:'al work, of the injured person ; and in some jurisdictions the ser\dces of the ex- perts may be called upon, by legal procedure, before the trial. One of the most interesting questions which this class of cases has created has had public attention recently directed to it by the passage of a statute of the State of New Yoi-k (L. 1893, chap. 721) providing that in an action for personal injuries the court may, and in cei-tain cases must, grant an order compelling the x^h^intiff to submit, before trial, to a physical ex- amination l)y one or m(n'e physicians or surgeons. It is left to the dis- cretion of the court whether or not to grant such an examination, unless the defendant shall present to the com't satisfactory e^•idence •' that he is ignorant of the nature and extent of the injmies complained of." This statute has come up for construction several times during the past year and has l)een the cause of nnicli discussion ; and in a recent case iu which a female infant sued the Manhattan Elevated Railway in the City of New York, and an order was obtained for her examination by a x>hysi- cian b(»fore trial, the statute was sharply attacked as an unconstitutional invasion of personal rights and the sanctity of the person, and was an- imadverted upon by the court ; but its constitutionality has been thus far upheld. According to the procedure under the New York statute the physician asks questions of the plaintiff, makes a physical examination, and reports his conclusion in wi'iting. This report is filed and may be used by either party on the trial. It certainly seems as if this statute would prove a salutary measure and tend to check the practice of bring- ing suits for large damages for very trifiing or non-existing injuries. 377 378 ^ SYSTEM OF LEGAL MEDICLXE. But the right to sueli an examination lias been lield by the Supreme Court of the United States not to exist at common law, and Mr. Justice Gray, in his opinion in the case of the Union Pacific Railway Co. vs. Botsford, 141 U. S. 250, says : " The inviolability of the person is as much invaded by a compulsory stripping and exposm-e as by a blow. To compel any one, and especially a woman, to lay bare the body, or to submit it to the touch of a stranger, without lawfiil authority, is an indignity, an assault, and a ti'espass." The rule was the same in New York previous to the passage of the statute above mentioned.* But in the States of Iowa, Ohio, Kansas, Wisconsin, Minnesota, Nebraska, Missouri, Ai-kansas, Texas^ Georgia, and Alabama it has 1:)een the jjractice of the court to gi-ant or- ders compelling the plaintiff to submit to a physical examination before trial. It is probable that in those States the j^laintiif would also be com- pelled to submit to a physical examination at the trial. But in New York, even since the passage of the act of 1893 before alluded to, such an examination cannot be compelled at the trial. The plaintiff may be requested to submit to such an examination, and if he refuse his refusal may be considered by the juiy as bearing on his good faith, but he can- not be compelled to undergo it. In the Union Pacific Railway case before cited Justices Brewer and Brown dissented \agorously from the conclu- sion reached by the majority of the com-t, and enunciated by Justice Gray, and said : " It seems strange that a plamtiff may, in the presence of a juiy, be jiermitted to roll up his sleeve and disclose on his arm a wound of which he testifies ; but when he testifies as to the existence of such a wound the court, though persuaded that he is perjuring himself, cannot require him to roll up his sleeve and thus make manifest the truth, nor require him in the like interest of truth to step into an adjoining room and lay bare his aitn to the inspection of sui'geons. It is said that there is a sanctity of the person which may not be outraged. We believe that truth and justice are more sacred than any personal consideration ; and if in other cases, in the interests of justice or from considerations of mercy, the coui'ts may, as they often do, require such personal examination, why should they not exercise the same power in cases like this, to prevent wi'ong and injustice ? " An analog^' to the case of compelling an examination of the person of the plaintiff in actions for personal injuries is to be found in the law of divorce. In actions for a di^'orce or for a decree of nullity on the ground of incapacity to consummate the marriage, it is the practice in England, Scotland, France, and generally in the American States, where the evi- dence is necessary, and can be obtained in no other way, for the court to order an inspection of the person by medical exi^erts. The same ob- jections have been lu-ged in divorce cases to such inspections as have been urged to an examination in actions for damages for personal inju- ries, and as far as the ^■iolation of the sanctity of the person is concerned the objection to an examination in di^'orce cases is more weighty, for the reason that the intrusion and violation of the subject's modesty are greater. But tlie necessity, it may be said, is also gi-eater. " It has been said," remarked Lord StowcU. '• that these modes resorted to for proof on these occasions are offensive to natural modesty. But nature has pro- * McQuiyan vs. D., L. cf- W. B. IL Co., 129 N. Y. 50. ACCIDENT CASES. 379 vided no other ineans ; and we must he under the necessity of saying that all relief is denied or of a[)plying the means within our power. The court must not saerifice justice to notions of its own." * Even in a case where a husband sued for divorce on the ground of the phj^sical incapacity of his wife, and his bill was taken for confessed, that is to say, the wife interposed no defense, Chancellor Walworth of New York ordered an exandnation of the defendant ]>y surgeons and matrons, and a report to the court. And that learned jurist, in discussing tlie application, said: "Investigations of the kind are always indelicate, and tlie mode of proof to which resort must of necessity be had must frequently be very distressing to the feelings of parties. This court, however, is not at liljerty to decline jurisdiction in such a case, Imt nnist proceed to the examination and decision thereof in the manner requu-ed l3y law, if the injured party thinks proper to insist iq)on his legal rights." t In many actions for personal injuries the plaintilf greatly exaggerates his injuries, even if he does not perjiu-e himself about them, and a medi- cal examination, conducted under proper safeguards and restrictions, would seem a wise check upon the temptation to such exaggerations or perjuries. And in connection with the natural anxiety of the phiintitf to make his condition out as bad as possible, a story is told of an action for personal injuries in the New York courts, in which the jjlaintift" tes- tified that his right arm had been so injured that he was unaljle to raise it any longer to a horizontal position. Upon cross-examination the de- fendant's counsel asked him to indicate how high he could now raise his arm. " Only so high," replied the witness, lifting his arm with apparent diificulty a few inches from his side. " And how high could 3'ou raise it before this unfortunate occurrence?" said the lawyer suddenly. "So high," replied the witness, raising this same injured arm above his head with ease. When it comes to the actual trial of actions for personal injui'ies there are two difficult questions, to the solution of which the testimony of the medical expert may be directed. One of these is how far the defendant's negligence is responsible for some subsequently developed infirmity or disease, or, in other words, how far a given injury may be said to be the •natural and proximate cause of a subsequently developed condition, and therefore render the defendant liable tov that contiition. The general rule is easily stated — to wit, if the subsequent disease or infirmity is one which would occur as the natural result of the injury, and it is not shown that any other independent cause existed of which it might have been the result, then the author of tlie original injury is lial)le for the subse- quent disease or infirmity. But, like all general rules of law, the diificulty of this rule lies in applying it to particular states of facts. Some illustra- tions may be useful. The question has frequently arisen where, in the case of women, it is claimed that a miscarriage is the ultimate result of the shock of an accident, though not of any direct physical injury. A pregnant woman was dri^dng with her brother over a defective bridge. The hind feet of the horses went through the bridge. The woman got out of the carriage and went for help, and claimed that her exertion in so doing and her fright brought on a miscarriage. It was left to the * Brif/f/ii vs. M<»-f/y the appellate courts. The plaintiff. Dr. Phillii)s, was an eminent London physician of middle age and robust health, earning an income from the practice of his profession of about £5000 a year. He was injured in a railway accident and his health irreparably impaired to such a degree as to render life a burden and a source of the utmost misery. His condition, as Lord Chief -Justice Coekburn put it, was at once helpless and hopeless. The expenses incurred by reason of the accident had al- ready, at the time of the first trial, amounted to £1000, and medical at- tendance to still more, and the latter was likely to be for a hmg time necessary. He had already lost his income for the period of sixteen months which liad elaj^sed between the time of the accident and the trial. On the first trial the juiy gave him £7000 damages. The Coiu't of Queen's Bench reversed the judgment and ordered a new trial on the ground of the insufficiency of the verdict, and this reversal was afiii-med by the Court of Appeal. Lord Coekburn said : " But w^e think that a jury cannot be said to take a reasonable view of the case unless they consider and take into account all the heads of damage in resjDect of which, a plaintiff complaining of a personal injury is entitled to compensation. These are the bodily injmy sustained ; the pain undergone ; the effect on the health of the sufferer, according to its degrees and its probable duration as likely to be temporary or permanent ; the expenses incidental to attempts to effect a cure or to lessen the amount of injury ; the pecuniary loss sustained through inability to attend to a profession or business, as to which, again, the injury may be of a tempo- . rary cliaracter or may be such as to incapacitate the party for the remainder of his life. If a jury have taken all these elements of damage into con- sideration, and have awarded what they deemed to be fail' and reasonable compensation under all the circumstances of the case, a court ought not, unless under very exceptional circumstances, to disturb their verdict. But looking to the figure in the present case it seems to us that the jmy must have omitted to take into account some of the heads of damage which w^n-e properly involved in the plaintiff's claim." t On the second trial, before Lord Chief-Justice Coleridge, the jury found a verdict for £10,000. This time the defendant appealed and the case again went to the Court of Appeal, but the judgment was affirmed. On the second appeal, in discussing the evidence upon which to base compen- sation for the loss of a professional or trade income. Lord Justice Brett said : '' It has been in effect suggested by the counsel for the defendants that * Sirnlim vs. .Y. T.. L. E. .f- W. JR. B. Co.. 9G N. Y. 305. t Fhilli_ps vs. Soutlncestern By. Co., 4 Q. B. D. 406. 584 ^ SYSTEM OF LEGAL MEDICINE. the amount of the income at the time of the accident ought not to be taken into account. This suggestion seems to me to be erroneous. . . .' If no accident had hapj)enecl, nevertheless many circumstances might have happened to prevent the j)laintiif from earning his j)rofessional income. He may be disabled by illness, he is subject to the ordinar}- accidents and vicissitudes of life, and if all those circumstances of which no evidence can be given are looked at it would be imj^ossible to exactl}^ estimate them. Yet if the jmy whoUy pass over them they will go wrong, because those accidents and ^dcissitudes ought to be taken into account. It is true that the chances of life cannot be accurately calculated, but the judge must tell the jury to consider them in order that they may give a fair and reasonable compensation." The plaintiff can alwa^-s recover the cost of medical attention, nui'sing, and all ordinary and reasonable expenses which he has incurred by reason of his sickness, and it has been held to l)e no defense to a recovery for money paid to a nui'se that the plaintiff had a family capable of taking care of liim. This last defense in these days of trained nm-sing strikes one as being a httle strained, and evidently struck the court so.* It has even been held that a plaintiff may recover the value of medical ser\dces gratuitously rendered, the reason being that these ser\T.ces were rendered for the benefit of the plaintiff and not for the benefit of the defendant, and the defendant should not, therefore, be allowed to profit by them. In one of the cases in which this rule was enunciated tlie plaintiff was a physician, and it was sought to prove that it was a luiiversal custom among phj^sicians and surgeons not to charge members of the profession for services rendered, but the evidence was held inadmissible as immate- rial.t The term "medical services and expenses" does not merely in- clude doctors' bids, medicines, and nursing, but covers also reasonable, necessary, and judicious trij)S to health-resorts; as, for instance, where a person injm-ed in a railway accident went to the Electric Wells in Geor- gia and the Glenn's Springs in South Carolina for treatment, he was allowed to prove the expense of these trips as part of his claim4 But where a parent sues for the loss of ser^dces of a child as the residt of an accident, he can recover as expenses for medical attendance only those actually incurred or immediately necessary ; future and contingent ex- penses are recoverable only by the child and not by the parent.§ * Kendall vs. Citii of Albia, Iowa Supreme Court, October 27, 1887. t City of Indianapolis vs. Gaston, 58 Ind. 224. X Bart vs. Charlotte B. Co., 32 S. C. 427. $ Jones vs. Chamherlain, 109 N, Y. 100. MENTAL DISTRESS AS AN ELEMENT OF DAMAGE IN CASES TO EECOVER FOR PERSONAL INJURIES. By JOHN E. PARSONS, Esq. It is common experience that anguish of mind, laceration of feehug, a sense of shame, of indignation, or of hnmihation, anxiet}^, distress of a sentimental character, are often more difficult to bear than hodily hurt. Where such injury has been occasioned by the fault of another, the ques- tion arises whether in every case the law affords redress. The maxim of the law is that for every wrong there is a sufficient remedy. Does this maxim hold true in all cases of the character referred to 1 The general principle is well estabhshed that in actions of tort, where for the wrong- there is a right to recover damages, mental distress may be taken into ■consideration in fixing the amount. But the weight of authority seems to establish that when the injury consists in distress of mind alone, or where the mental distress is separate from and independent of the ^^a•oug, it does not constitute an element of damage and ma}' not be considered in determining the amount of a recovery. In support of the general proposition, Mclnf\jre vs. Gihlin, 131 U. S. 174, is a receut authority. This was a suit to recover danuxges for the careless shooting and wounding of Giblin by Mclntyre. On the trial the court charged the jury that in computing the damages they nught take into consideration ''a. fair compensation for the physical and niotfal suf- fering caused by the injury." The United States Supreme Court, Chief- Justice Waite delivering the opinion, held that there was no error in permitting a recovery for mental suffering. The court said that the €ffe(;t of the instruction was no more than to allo^^' the jury to give eom- peusation for the personal suffering of the plaintiff caused by the injurv. In Hamilton vs. Third Avenue R. R., 53 N. Y. 25 (1873), the Court of Appeals of the State of New York held, where the plaintiff was forcibly ■ejected from one of the defendant's cars because of his refusal to pay his fare a second time, that the injury to his feelings uiiglit be taken' into consideration by the jury and a suitable recouipense giveu therefor. In Hamilton vs. Uno, 81 N. Y. IIG, the same court aflirnied the decision of the General Term of the Supreme Court {Hamilton ys.Uno, 16 Hun, 599), holding in an action for libel that, in a case where damage had been shown, injury to feelings ndght be treated as a proper subject for con- sideration. Other illustrations of tlie general rule will be found in cases decided 385 386 ^ SYSTEM OF LEGAL MEDIC IXE. by the Euglisli courts and by the coui'ts of mauy of the States. Thus in Blal-e vs. Midland Raihvay Co., 18 Q. B. 93, Coleridge, J., said: ''When an action is brought by an individual for a personal ^vi'ong, the jury, in assessing the damages, can with little ditficulty award him a solatium for his mental sutferings alone, with an indemnity for his pecuniary loss." Godeau vs. Blood, 52 Vt. 251, was a case where a child was bitten by a vicious dog. Redfield, J., said that the apprehension of poison from the bite of the dog, and the fear and solicitude as to evil results therefrom, w^ere proper matters for consideration hj the jury in estimating the dam- ages. In Reddles vs. Railway Co., 11 Wis. 228, it ajjpeared that one of the defendant's engines ran over a boy and crushed both his legs. It was held on appeal that damages might be awarded for the "mortifica- tion and anguish of mind which he has suffered and will suffer in the future by reason of the mutilation of his body and the fact that he may become an object of curiosity and ridicule among his feUows." Seger vs. Toivn of BarA'Jiamsfead, 22 Conn. 290 ; 8herwood vs. Railway Co., 88 Mich. 108 ; and Railroad Co. vs. Stables, 62 111. 313, are similar cases. Kennedy vs. Standard Sugar-refining Co., 125 Mass. 90, states the prin- ciple under novel circumstances. Kennedy, an employee of the defend- ant, fell several stories and was killed. The fall was due to a defective floor. When he struck the ground he became unconscious and remained so until death. This action was brought by his administratrix. At nisi prius the mental sufferings of the deceased dmlng the faU were allowed as an element of damage. Morton, J., on apjDeal, said : " It may be true^ as an abstract proposition of law, that if a man is precipitated from a height by the negligence of another, and is injiu'ed, he may recover, as- one element of his damages, for any mental suffering he may prove he endured during his fall." Damages were refused simply because, Ken- nedy having remained unconscious till death, there was no way of prov- ing mental suffering. The cases aU proceed upon the principle that where personal injury has been inflicted, for which the wrong-doer can be made liable, mental distress may be taken into account as well as injmy to person or char- acter. Some go to an extreme length in permitting a recovery where it is wounded feeling, mortification, indignity, or a sense of humiliation in which consists substantially the entire injury. Thus in Cral'er vs. Rail- ivay Co., 36 Wis. 657, it was held that a female passenger on a railway- train could recover for the sense of shame and personal affront which accompanied the act of the conductor of the train in placing his arm around her against her protest, and kissing her. Ob\dousl5^ in this case the bodily injury was nominal. It was for the indignity that the plaint- iff was permitted to hold the company liable. The extent to which courts have gone in grasping at the slightest proof of bodily harm to permit a recovery for distress of mind occasioned by the same occurrence is illustrated by many cases. Railroad Co. vs. Brown, 17 Wallace, 445, and Railway Co. vs. Williams, 55 111. 185, were suits brought by female colored passengers who were not permitted to sit in cars reserved for ladies. In the first case the Supreme Court of the United States refused to disturb a verdict of $1500, although the passenger aggrieved was car- ried safely to her destination ; and in the second it was held upon appeal that a verdict of $200 was not excessive, Scott, J., saying: "We appre- hend that if the act is wrongfully and wantonly committed the party MENTAL DISTRESS. 337 may recover, in addition to the actual damages, something for the indig- nity, vexation, and disgrace to whicli the party has been subjected.'' In Anonymous, Minor (iUa.), 52, it appeared that one broke into the liouse of anotlier without a warrant, under pretense of searching for stolen money. The court said: "He [phiintiff] may have sustained no- pecuniary h)ss, but the injmy fixes on liim the eye of public suspicion,, inflicts a rankling wound on his feelings, and tends to jn-osti-ate liis character." It was held tliat for such injury to liis feelings the plaintitf might recover. In CuituuiiKj vs. Iiiliabifaiii.s of WiUiauinhKiy, 1 Cusliing,. 451, Metcalf, J., said: "Though that bodily injury may have been very small, yet if it was a ground of action within the statute, and caused mental suffering to the plaintiff, that suffering was a part of the injury for wliicli he was entitled to damages." ( Vide, also, Curtis vs. Railivai/ Co., Supreme Court of Iowa (1893), 54 Northwestern Reporter, 339 ; 117//- Konvs. Railroad Co., 5 Wash. 621 (1893); Chicago, etc., R. R. Co. vs. Con- leij, 6 Indiana Appellate Court Rej^orts, 9 (1892); t'ihepard vs. RaiJwaij Co.. 11 Iowa, 54 (1889) ; The LaJie Erie, etc.. Railway Co. vs. Fix, 88 Ind.. 381 (1882) ; Chicago, etc., R. R. Co. vs. Flagg, 43 111. 364 (1867).) What remains to consider is the right to recover for mer« mental distress consequent upon the negligence or misconduct of another. Upon this subject an interesting and instructive case is Lynch vs. Knight, 9 H. of L. Cas. 598. The case came to the House of Lords from the Irish Court of Exchequer Chamber. It was heard just before the death of Lord Camijbell. He left a written decision which, with comments by way of partial dissent, was read by his successor, Lord Brougham. The- defendant had impugned the chastity of the plaintiff's wife in terms which were not actionable |)er se. The husband sued in his own right^ joining his wife, and recovered £150 for the deprivation of her society^ he luiving sent her home to her parents in consequence of the imputation upon her conduct. All the judges agreed, there being no evidence of special damage, that a recovery for mental suffering could not be sus- tained. Hyatt vs. Adams, 16 3Iicli. 180, is to the same effect. The action was brought to recover damages sustained by the plaintiff by reason of malpractice resulting in the death of his yMe. The plaintiff claimed damages for his mental agony on account of his wife's sufferings for the- three days prior to her death. Christiancy, J., in overiiiling the charge of the judge below, speaks of " the propriety and good sense of the rule which restricts the right of action for mental suffering to the person who has received the physical injiu-y." Connell vs. Western Union Telegraph Co., 116 Mo. 34, deals with the general suljject in a very able way. The case was elaboratel_y discussed, all the leading authorities upon the sub- ject being referred to. The action was to recover danuiges for the negli- gence of the defendant in failing to deliver to the plaintiff the followiug^ telegraphic message sent to him bv his wife : " Sedalia, Mo., December 13, 1889. To Matt. Connell, Soldiers' Home, Leavenworth, Kansas. Your child is dving. Marv." The child died on December 24, 1889. The plaintiff, claiming tliat the defendant had negligently failed to deliver the message, and that in consequence he had been unable to attend the funeral of his child, brought suit to recover among other things for the mental anguish and prostra- tion wliich he had suffered. The court held tliat he could not recover, the mental distress not having attended upon or been accompanied by 388 -4 SYSTEM OF LEGAL MEDICINE. pliysieal injury. Tlie same principle was decided in Wilcox vs. Richmond d' D. II. Co., 52 Federal Reporter, 264. The complaint alleged tliat the plaintiff, being informed by telegraph of the dangerons illness of his father, engaged defendant to convey him to Columbia, S. C, where his father TS'as, in a fixed time, pa;s'ing for the service $195. The plaintitf charged that the defendant refused to perform its agreement, and that as a consequence he suffered gi-eat distress of mind, anxiety, mortifica- tion, and suspense, for which he claimed $5000 damages. There was a second cause of action for the return of the $195. The plaintiff was per- mitted to recover the latter amount, but the C'ii'cuit Com-t of the United States for the Distiict of South Carolina. Chief-Justice Fuller sitting with the Circuit Judge and District Judge, affirmed a decision by which it was held, on the authority of Lynch vs. Knight, that for mental pain alone, unattended by injuiy to the person, caused liy simple neghgence, an action could not be sustained. - Victoria Baihvay Commission vs. Coultas, L. E., 13 App. Cas. 222 (1888), privy council on appeal from Supreme Court of Victoria, is a recent case. A female crossing a railroad track in a wagon just escaped being dashed into by a jjassing ti'ain, in consequence of the negligence of an employee. She received a severe nervous shock fi-om ft-ight, and the con- sequence of the fright was an attack of illness. On appeal it was held tjiat for this she could not recover, the damages being too remote. Sir Ei chard Couch, in delivering the opinion of the court, said : " Damages arising fi'om mere sudden teiTor unaccompanied by any actual physical injury, but occasioning a neiwous or mental shock, cannot luider such circxun stances, their lordships think, be considered a consequence which in the ordinary coiu'se of things would flow from the neghgence of the gate-keeper." To the same effect are Eicing vs. Baihvay Co., 147 Pa. St., 40 : City of Salina vs. Trosper, 27 Kan. 544 ; Wymnn vs. Leavitt, 71 Me. 227. In EaUroad Co. vs. Staples, 62 HI. 313, it appeared that Stables, while crossing a raih'oad track, was struck by a passing train. His wagon was broken and he was severely injui^ed. The coui-t held that for his mental sufferings Stables could recover, saying : " The mental anguish which would not be proper to be considered is where it is not connected with the bodily injury,, but was caused by some mental con- ception not arising from the physical injuiy." It is proper to state that although the cases cited and others seem to settle the rule that for mere mental distress there can be no recovery, their authority- has not gone imquestioned. In Bell vs. The Great Xorth- ern Baihvay Co., 26 L. E., Ireland, 428 (1890), the com-t expressly refused to follow Victoria Bailtvay Commission vs. Coultas. The plaintiff was put in gi'eat fright by the anticipation of a collision. She suffered fi-om nervous shock and ill health in consequence. She sustained no bodily injiuy. It was held on appeal that, since the fright was the direct conse- quence of the occurrence and the plaintiff's ill health the consequence of the fright, damages might be recovered for impairment of liealth. And in some of the States it has been stoutly maintained that there might be a recovery for neiwous shock or mental distress where there was no bodily or pecuniary loss. Hale vs. Bonner, 82 Tex. 33, was such a case. The plaintiff sued to recover damages for breach of contract on the part of the defendant in failing to deliver promptly the body of her deceased husband. The contract was for carriage from San Antonio to MENTAL DISTRESS. 389 Jefferson. Wlien the train arrived at Jefferson, where many friend^ Avere wjiiting- to accomjjany the body home, it Avas not on ))oard, to phiint- iff's great distress of mind. When tlie body did arrive it was in an ad yan(!ed stage of decomposition, wlueli caused the i)laintitt' a(kliti()nal pain of mind. A demurrer was sustained in the court l)eh)w. On ap]jeal the ju(]gment entered on tlie demurrer was reversed. M^estern Union Teleijnqjh Co. vs. Xcwhoiise, G Indiana Appellate Court Keports, 422 (1892), is a case in which a plaintiff' was permitted to recover because he failed to see his mother before her death in consequence of the failure of the defendant to deliver a telegram. Womadi vs. The Western Union Tele- graph Co., 22 Southwestern Reporter, 417 (1893), Court of Civil Appeals (^)f Texas, is to the same effect. These and numerous other cases are reviewed ^^Adth great ability by Gannt, P. J., in Connell vs. Western Union Telegraph Co., prcAdously cited. He said: "We are fidly aware that the plaintiff''s claim appeals strongly to the sensibilities ; but to adopt that view we must either be guilty of .adopting one ride of damages for one class of common can-iers, and the breach of their contract, or we must conclude that all of om* predecessors in the great common-law coui'ts were at fault, and henceforth repudiate not only their utterances but our own on this subject, and this we have no inclination to do. We prefer to travel yet awhile super antiqnas vias. If, in the evolution of society and the law, this innovation shoidd be deemed necessary, the legislature can be safely trusted to introduce it, with those limitations and safeguards which will be absolutely necessary, judging from the variety of cases that have sprung up since the promul- gation of the Texas case." This may be accepted as an accm-ate statement of the present state of the law upon the subject. rEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. PHILIP COOMBS KNAPP, A.M., M.D. There are two great motives wliieli incite a man to feign disease — the desire to escape from something unpleasant, and the desire for gain. The first motive is most potent among criminals and soldiers. In the former class responsibility for criminal acts may be lessened by proof of mental disease, and illness may alleviate the discomforts of jDrison life, or even obtain a pardon. The criminal and the loafer in our pub- lic institutions by simulating disease can often escaj^e from the hated work and perhaps obtain the more agreeable diet of a hospital. In mil- itary life the illnesses which develop just before a battle have caused ''sogering" to become synonymous mtli malingering, and in countries where compulsory military service exists, numerous devices are reported as practiced by those who desire to escape conscription. The second motive for feigning disease is the one which will most likely be met with by the physician in ordinaiy practice. There are many ways in modern life in which a man, although in the exercise of due care, may suffer personal injury by another's negligence; and, consequent^, the dockets of our courts are filled with suits for damages, and railway coi'porations are compelled to pay large sums for such purposes, a single corporation in Boston pajdng annually on an average over $150,000. Such acci- dents also lead to claims against insurance companies and charitable associations. In other cases, the desire for a pension may be the cause which leads the claimant to feign disease. Considering, therefore, the large number of persons whose moi'al sense is, to say the least, defective, it would not be strange if many fraudulent cases presented themselves before the claim-agents, and if feigning were common. "With the advance in our knowledge of disease and in the methods of clinical research it is obvious that the difficulty of simulation is enor- mously increased. Only those affections the s^-mptoms of which are subjective can be successfully feigned. The stethoscope, the ophthalmo- scope, and the microscope give us testimony which the malingerer can- not counterfeit ; consequently the majority of surgical affecti(Uis, together with most of the diseases of the lungs, heart, and kidue^y, which present symptoms clearly objective, cannot be sinnilated so as to deceive the trained physician. It is in the domain of the nervous system that the majority of cases of alleged simulation occur. Many phvsicians are 391 392 -^ SYSTEM OF LEGAL MEDLCINE. unfamiliar with tlie rarer forms of nervous disease and with the newer methods of diagnosis, and many of the symptoms are purely subjective. The feigning of a broken leg is practically unheard of ; the feigning of the various conditions classed as traumatic neuroses is claimed to be ex- tremely common. Statistics as to the frequency of feigning are somewhat uncertain, and show great variations. My personal belief is that simulation in any form is rare, and that successful simulation, if the examining physician be competent, is even rarer. Out of 23,903 surgical cases admitted to the Boston City Hospital in ten years, the diagnosis of malingering was made in two, and in 30,639 medical cases the diagnosis was made in fif- teen. As might naturally be expected, mahngering is more frequent in the office of the admitting j)hysician of the hospital, where a considerable number of the simulators are detected and turned away. In addition to the cases which were admitted to the hospital in the ten years, there were 15,957 rejections, and of these 511 were refused admission, the cause being assigned "no disease and mahngering." Of these 511 rejec- tions, the admitting phj^sicians considered about one fourth were cases of malingerers who were anxious to get the shelter and food of the hospital ; the other three fourths were not suffering from any disease. These latter figui-es, however, show merely the number of rejections, and not the number of persons, for it has sometimes happened that a mahn- gerer has been turned away eight or ten times in the course of a year. In penal institutions malingering seems to be distinctly more com- mon, but its frequency seems to depend somewhat upon the strictness- of the prison discipline. A considerable number of prisoners will report to the physician at sick-call in the morning for the sake of escaping from work for a time, or in the hope of being admitted to the prison hospital ; but such cases are usuall}^ readily detected, and they seldom attempt such a proceeding except upon a new physician whom they think is inexperienced. In my own ex]3erieuce and in that of my colleagues at the Suffolk County House of Correction in Boston, there were many cases who, we thought, came to sick-call when there Avas no real disease ; but the physicians who have been in charge at the House of Correction in recent years agree that there have been very few eases of dehberate and persistent simulation of any form of disease or of insanity. Dr. W. B. Bancroft, the present physician, has informed me that, in his opinion, simulation was distinctly rare ; that in five years fifty x)risoners have been committed to insane asylums, and that there were only three cases where insanity was dehberately feigned. Dr. G. F. Jelly, the examiner in lunacy for the public institutions, coincides in this opinion, and adds that cer- tain cases, which were believed to have feigned insanity, gave cAddence of genuine insanity after admission to an asylum. At the Massachusetts Reformatory Prison at Concord Dr. Gr. E. Titcomb writes that there is little simulation ; however, the men have a powerful motive for refrain- ing from deceit, because the length of their sentence is determined by good behavior. Where prison discipline is relaxed, however, mahnger- ing becomes much more frequent. Dr. C. D. Sawin wi'ites me that at tlie Massachusetts State-prison at Charlestown, where the discipline has been very lax, feigning has been extremely common, but usually it has been readily detected. Statistics from the pension offices as to simulation are not easily to FEIGNED DISEASES OF THE 2IIXD AND MiRIOUS SYSTEM. 393 be obtained in sufficient numbers to give a definite opinion, but the im- pression of severtil of the examiners seems to be that deliberate, conscious simuhition is i"ire. The (juestion as to the frequency of simulation has been most dis- cussed with refei-ence to the claims for danuxg-es for personal injuries, and here opinions vary very greatly. Hodges {Boston Med. and Surr/. Journal, April, 1881) believed that out of 21 cases he had seen, 10 were fraudulent and 6 were doubtful. Rigler {Rerne Medicale, January, 1879, Ueber die Folgen der Verletzungen auf Elsenhalinen) out of 28 cases thought 7 were fraudulent and 13 doubtful. Page {Tiijnrie.i- nal Cord) in 234 cases considered simulation or gross exaggeration to be veiy common. To these figures, however, the objection may at once be raised that they are the opinions of surgeons accustomed to deal with ol)jective symptoms, and unfamiliar ^\dth the subtler and more obscure phenomena found in nervous diseases. It is obvious that only a man with long experience in the observation of patients with mental and nerv- ous diseases can judge correctly of the reality of nervous sjmiptoms. It is only within a very few years that neurologists have l:)rouglit forward statistics sho■\^dng the frequency of simulation. In 1890 J. H. Hoffmann {Berlin. l-lin.Wochenschr., July, 1890) started a discussion upon this sub- ject, Avhich was carried on at the Berlin International Medical Congress in the same jea,Y by Schultze {Sammlung Min. Vorfrdge, No. 14, 1890), Seeligmiiller {DeutseJie med. Wochenschr., October, 1890), Mendel, and others {Verliand. des X. internat. med. Congress, B. iv., Ab. ix.). The writers mentioned claimed that in the so-called traumatic neu- roses simulation was extremely common, existing in from one fourth to one third of all the cases. The cases which they published in support of their opinions are not, however, absolutely conclusive ; the variable character of symptoms often observed in hysteria and neurasthenia, and some of the subtler peculiarities in those symptoms, seem to have been overlooked, and in more than one instance the destructive criticism of Dubois {Corr.-Bl. f. scliweiz. Aerzte, September, 1893), Mobius {Miincli. med. Wochenschr., September, 1891), Oppeuheim ( ^Yeife)^e Mitfheiluugen in Bezug auf die traum. Neiirosen), and others, has shown that the accusation of simulation was not substantiated. Indeed, in a later communication, Schultze {Deutsche Zeitschr. f. Nervenheilh., vol. i., p. 445) found only ten percent, of simulation instead of thirty, as in his previous series. It is clear that simulation ought frequently to be seen in the claim- agent's room more than in the office of the neurologist, and claim-agents, corporation lawyers, and railway surgeons are fond of saying that the vast majority of cases are frauds. The more pronounced cases of simulation are recognized at once, and only the doubtful cases run the gauntlet successfully and are subjected to the expert judgment of the neurolo- gist. Even in the whole nniss of cases that come to the claim-agent's office, however, the amount of deliberate simulation seems to be small. Dr. M. D. Field {Traits. Am. Keur. Assoc, 1893; Joiirn. Xerr. and Mrut. J)is., March, 1894), the examining surgeon of the Manhattan Elevated Eailway, has stated that deliberate sinnilation is seen only in a very small percentage of the eases, and that in such cases it is so manifest and the s3'mptoms are so grossly exaggerated as to be at once recognized by a trained observer. Other examining physicians have expressed to me similar opinions. My own personal experience coincides fully ^^'ith 394 ^ SYSTEM OF LEGAL MEDICINE. tliese views. In less tlian four percent, of the cases that have come under my own observation was simulation at all probable, and I have succeeded in demonstrating- the genuineness of the symptoms in some cases where simulation was claimed by good observers, and I have also known some suspected cases to terminate fatally. Exaggeration of symptoms is more common, but it must be remembered that exaggera- tion is a common feature in all sorts of nervous diseases, where intro- spectiveness, hypochondriasis, and fear lead the patient to make much of minor ailments. The possibility of the successful simulation of the various forms of nervous disease is not great, provided the investigator be familiar mth the clinical manifestations. The sijnulator's task is not easy. He must Ibe as familiar with all the symptoms of the feigned disease as the phy- isician is, he must be prepared for aU the forms and variations of tests employed in a clinical examination, and he must be constantly on his guard lest he betray himself by some unguarded admission. It is clear that such knowledge and such skiU are beyond the g:rasp of the average patient. Many of the minor symptoms of nervous clisease and the more €xact and elaborate methods employed in their diagnosis are unknown even to the average physician, and the patient cannot learn of some of them unless he is able to read a foreign language. Granting that he could acquire this knowledge, or that he could find a physician suffi- ciently expert to coach him, another diificulty stands in the way: he must simulate all these symptoms accurately before a physician at least as weU acquainted with them as his coach, familiar with aU the symptoms of the disease feigned, and ready at any mistake to catch hun off his guard. Recent psychological investigations, however, have shown that a man can keep his mind fixed upon any special topic only for a short time. Hence most persons, even if they know the particular movement which constitutes the "trick" of a sleight-of-hand performance, will fail to note it because the performer chooses the one moment to make that movement when their attention is distracted. The simiQator must be prepared to feign a dozen symptoms at the same time, so that his task becomes much more formidable, and a successful examiner can readily take him off his guard by the application of some unexpected test. This lias been clearly shown by Pitres {Lemons cVmiques sur Vliysterie, vol. i., p, 79), who had a remarkably good opportunity to prove it. A man had for several years taken the part of the ana?sthetic man in a show, en- during pricks, cuts, etc., without the slightest manifestation of pain. In order to obtain the shelter of hospital life this man feigned a disease, one symptom of Avhich was anesthesia ; but when he was subjected to the unexpected application of painful stimuli Pitres proved at once that the anaesthesia was feigned. One of the striking characteristics of the average simulator is that his ^symptoms are usually pronounced, and are always made prominent in the clinical picture. There is paralysis, not weakness ; antesthesia, not diminished sensibility ; violent pain, not aching. He calls attention to iiis symptoms ; they do not have to be sought for by special tests in a clinical examination. Such symptoms as a moderate contraction of the -visual field, a diminished sensibility to pain or temperature, with normal isensibility to touch, or the quibblings or questionings of insanity of Joubt, have nothing to do with his complaints. Tlie exaggeration of FEiaXED DISEASES OF THE MIX I) AM) S EI! 10 US SYSTEM. ^95 syniptoins, the manner of thrusting them before the examiner, the ab- sence of any shading- or qnalification, the total absence of objective phe- nomena, the detection of false statements -with i-egard to certain symp- toms of a partly objective character, and the like, render the detection of fi-and easy. It nnist be borne in mind, however, that contradictory statements and even conflicting data from examinations are l)y no means absolute proof of simulation. A very limited acquaintance with patients suffer- ing from actual disease will prove how contradictory their statements sometimes nuiy be, and, in nervous troubles especiall}', how their condi- tion may vary from one hour to the next ; what an influence expectant attention has upon their symptoms 5 and how suggestible they may be to the slig]]test influence. Certain conditions, too, may seem absolutely contradictory, and may, to the inexperienced, seem absolute proof of the unreality of all the patient's complaints. Thus, tenderness so extreme that the slightest touch cannot be borne may be associated ^vith com- parative insensibility to deep pressure; hysterical amblyopia may be shown to be really psychical, and to exist only on monocular vision ; complete inability to stand or walk, as in astasia-abasia, may be associ- ated with normal strength and power of coordination in the legs, and the like ; so that, without knowledge of such conditions, the diagnosis of simulation is often incorrectly made. In the detection of attempts to feign disease certain general rules are to be borne in mind. Whenever it is possible, confirmatory evidence should be sought from disinterested persons in regard to the patient's condition. Then the histoiy should be obtained from the patient him- self. Careful inquiry should be made in regard to all the bodily func- tions, and detailed inquiries in regard to all his complaints. The simu- lator usually proclaims all his sulferings loudly, but the genuine sufferer may often require close cross-examination to elicit the Avhole story. It is well to i-eturn after an interval to certain symptoms in order to see whether the patient's story is consistent or not, and to ask if he has ever had certain symptoms, either impossible in themselves or inconsistent with the type of disease he presents. It must be remembered that many people are incapable of telling a connected story or of giving an accurate account of real sufferings, that many affections show pronounced varia- tions, and that sometimes the claim that the symptoms always remain the same, or of the same severity, may of itself be suspicions. During the process of taking the history, the patient should be quietly and un- obtrusively watched, and it may be that he will be detected in performing some act which he has just announced himself incapable of performing. The taking of the case history sliould be followed by a thorough and complete physical examination, paying especial attention to the motor functions, sensation (including sensibility to pain and temperature as well as to touch), the si)ecial senses (always including exnmination with the ophthalmoscope and perimeter), nutrition, the electrical reactions, the reflexes, and the condition of the internal organs. It is safe to say that if there be any real disease of the nervous system such a complete ex- amination A^dll reveal some symptoms which it is either impossible or extremely improbable for the patient to fi'ign. Among the symptoms which cannot be feigned are optic neiiritis and atrophy, Argyll-Robertson pupils, nystagmus, muscular atrophy, reactions of degeneration, loss of 396 -4 SYSTE2I OF LEGAL MEDICINE. knee-jerk, ankle clonus, and a difference in the activity of the skin and tendon reflexes on the two sides. After this the physician "otII probably be in a position to give a defiuite opinion. Sometimes relocated exami- nations will be necessaiy, and in rare cases it may be necessary to apply the crucial test of protracted observation in a hospital. Seehgmiiller {Art. cif.; VerliamU. des X. Intermit. Med. Conyress, B. iv., Ab. ix.) has urged this, and thinks it ad\dsable to estabhsh observation hosjDitals where patients who claim damages on account of traumatic nervous affections may be sent. In very few cases, however, would such hospitals be re- quii'ed. Until the physician be absolutely con\TJiced, after a thorough exami- nation, that the patient is feigning, it is important not to treat him as a mahngerer. Such a eoui-se will directly antagonize the patient and- his friends, and the cases of deliberate feigning are too few to justify it. The suggestion made long ago by Casper {Handh. d. GericJitl. Med., B. i., Ab. V.) that the physician should make unexpected visits to the patient to catch him off' his guard would naturally arouse suspicion, and thus do more harm than good, and this, and similar proceedings, will seldom be found necessary. With a thorough knowledge of modern methods of clinical research, the old brutal methods of ignorance must be abandoned. Flagellations, douches, and the cautery may injure one who is really suffering, and they give no help to the scientific obserN^er. Even the so-called crucial ex- periment of etherization will rarely be necessary. It is of legitimate use in the diagnosis of certain affections, as is well known ; but it is not whoUy devoid of danger, and it shoidd be employed in suspected simula- tion only in cases where we might legitimate^ employ it in ordinary diagnosis. Many writers point out the danger to the malingerer of feigniug dis- ease. B}^ persistently feigning certain s^anptoms there is danger that a morbid habit may be established, and the feigned disease may become real. This is held to be especially true of attempts to feign insanity. I have seen one case where, in order to obtain a jjardon, a prisoner at fii'st deliberately induced vomiting, but finally the vomiting got beyond his control, and although he became alarmed at his condition and wanted to stop, he was for some time unable to control the vomiting. In manj^ cases, however, allowance must be made for the mistakes of the physi- cian, who regards the early symj^toms of mental or nervous disease as feigned, onlj- to find out later that there is really trouble. I have spoken thus far of the deliberate feigning of disease. There are, however, foiu" conditions to be borne in mind by the ph^'sician in examining the ordinary cases : first, eases where no disease exists and all the sjTiiptoms are deliberately feigned ; second, where there is some disease, but the symptoms are greatly exaggerated and additional symp- toms perhaps feigned ; thu-d, where certain morliid conditions are delib- eratel}" produced b}' the patient, such as conjunctiWtis, skin affections,, and the like : fourth, where the symptoms, although genuine, are not due to the alleged cause but have existed long before. Although deliberate simulation is, in my oi)iiiiou, rare, and is usually easily to be detected, it is a harder matter to determine, when there is genuine disease, how far the complaints are exaggerated. In many cases exaggeration is in itself a sjTuptom of nervous disturbance; iutrospectiveness, hypochondria. FEIGNED DISEASES OF THE MIM) AND NERl'OUS SYSTEM. Ijijj and exafi:^eratioii are cLaractoristics of tlie Dicntal foiidition of many nervous patients. To appreeiate these conditions justly i-ecpiires long familiiirity with nervous patients and nervous affections; and, as a rule, the physician and the fi-ieuds are too apt to undervalue their coni})laints. For the detection of exa^"y the hand on some group of muscles, such as the thigh muscles ; after a time these muscles will relax ; if then an attempt be made to flex the limb the simulator will contract the muscles again. If the clenched hand be opened during a genuine attack it will not be closed again — a simu- lator is apt to close it. After a severe attack, as was first pc^inted out by Hughlings Jackson {Medical Times and Gazette, February, 1881), and 400 A SYSTJEM OF LEGAL MEDICINE. as I have myself seen in several cases, there may be ankle clonns or loss of knee-jerk, s^nnptoms wkicli cannot be feigned. After a succession of fits the temperatnre rises, in exti'eme cases reaching 40° C. or more (104° or 105° F.). The confii-med epileptic has a characteristic facial ex- 23ression, f amihar to all who have seen many cases ; his face is often dis- figm-ed by the bromide-acne, and the tongue, head, and body often bear scars from the injuries received in the attacks. The simulator of epilepsy can be unmasked in various ways. "West- phal [Berlin. Min.WochenscJir., No. 40, 1878) and Winkler (Heller, op. cit., p. 33) have both detected cases by sajdng in the patient's presence that certain movements, such as no epileptic performs (for instance, extending the arm and spreading the fingers), ought to be performed in the attack, and the simulator in his next attack performed them. Tamassia [Rivista sper. di freniafria, vol. x^dii., p. 140) reports a case of a woman who feig'ned spnptoms of insanity and epilepsy. He found that she remembered what happened dui'ing her attacks, and, after she had overheard his in- quiiies as to whether she had certain symptoms in her attacks, she pro- truded her tongue to the left dimng an attack, vomited, contracted her fingers in a curious way, cried out in a way unlike the epileptic cry, kept the left arm rigid and the right arm flaccid, protruded the tongue when asked to do so, and finally had an attack when the cer^dcal vertebras were pressed upon — none of which sjmiptoms had she shown before they were spoken of in her iDresence. A prisoner at the Massachusetts State-prison -ceased his con^o^dsion when it was proposed to give him ether, of which he stood in great di^ead. Given a motive for feigning, it is ground for suspicion when a patient has a fit in the physician's presence. Out of ninety cases of epilepsy in patients who were able to come to see me I recall but three who have ever had fits during such a visit, and it is often difiicult to get the oppor- tunity of obser^dng a fit from its beginning when the patient is in tlie w^ards of a hospital. Partly from the occurrence of a fit on his first ^dsit and partly because the patient did not close the hand over the thumb, Macdonald {Boston Med. and Sxrg. Jour., December, 1S80) was able to un- mask the " dummy-chucker" Clegg, who had baffled many prison officials and jjh^^sicians, and had several times escaped punishment or prison duty on account of his supposed epilepsy. This case was so remarkable that it merits a brief notice. Clegg, by much study and observation, had learned to imitate fits very accurately. In an attack he made no mani- festation of feeling when pins were thrust under his nails or when the cornea was toiit^hed ; he turned livid, bloodj'' frothy saliva came from the mouth, his head was turned back, and the trunk was twisted in an attack. In one attack he had clonic spasm of the muscles of the neck so that the head was beaten against the floor mth force enough to abrade the scalp. He could assume the characteristic facial expression perfectly, and he had various scars on his head and body to which he was fond of calling attention. Knowing that simulators rarely fall so as to hurt themselves, he once had a fit in the gallery of the prison and rolled off thirty feet to the pavement beneath, breaking one or two bones. The reasons which led to the detection of his simulation were the defiinte motive he had for feigning, the fact that he had a fit on the ]3hysician's first visit, the way he called attention to his trouble and his scai-s, the change from the epileptic to a natural expression when he thought no one saw him, the FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 401 faet tlirtt in llio fit the fincrei-s were not closed over the thiiinl), tlie nails wei-e not livid, the rigidity could be easily overeome, the hands closed ygain after they were once opened, the sphincters were not relaxed, and finally, that there were no ecchymoses, extravasations, or .petechia? on his jjerson. There is another form of convulsive seizure, however, which some- times resembles epilepsy, 3-et in which many of the plienomena which in epilepsy suggest simidation may actually occur. In hysterical attacks the patient may have a seiziu'e at sucli a time as strongly to suggest the desire for display, consciousness is not wholly lost, tlie patient seldom falls so as to hurt himself, and the sphincters are not relaxed. The grand attack of h^'steria is rare in America, and its stages of epileptiform con- vulsions, contractions and gTaud movements, j^lastic poses and passion- ate attitudes, and delirium, demand such great knowledge, such mimetic power, and such extraordinary muscular control that it can seldom be successfully counterfeited. In lesser attacks we nmst rely for the dem- onstration of the reality of the affection partly upon the careful obseiwa- tion of the attack, but chiefly upon the disco\'ei"y of other symptoms of Jiysteria. In some cases we may find regions where pressure will pro- voke an attack — hysterogenous zones — or regions where pressui-e ^vill check an attack — hysterophrenic zones — but such zones are seldom found in patients in this country. After an hysterical attack Gilles de la Tou- rette and Cathelineau {La mdriiion dans Vlujsterie) have found that the -amount of urine was somewhat decreased for the ensuing twenty-four hom-s, that the solid constituents (urea and phosphates) were one tlm-d less, and that the ratio between the earthy and alkaline phosphates, which is normally from one to three, rose to from one to two or even to eciual- ity. Wliere there are no attacks the urine is usually normal. It is important also to determine the genuineness of the post-epileptic Tinconsciousness, as well as unconsciousness arising from any other cause. If fu'm pressure be exerted upon the supra-orbital nerve as it emerges fi'om the notch, the pain soon becomes too great for the simulator to bear. Similar results may be obtained by the fai'adic brush or by the needle-point electrode witli a very strong faradic ciu'rent. Contracture. — lu certain forms of paralysis contracture of the affected limb becomes an important s^Tiiptom, but it is impossible to feign it successfidly. On passive motion the physician can at once detect the difference between the tonic rigidity of true contracture, the limb being absolutely stiff and yielding gradually a trifle to pressure, and the active resistance of voluntary musciilar conti'action where the resistance is more irregular. The attempt voluntarily to resist passive movements will also be indicated by an increase in the pulse and respiration, flushing of the face, and, if more strength be applied, by the active resistance of other muscles of the body. In contracture, too, there is often an increase in the tendon reflexes in tlie affected part. In catalepsy the contracture of the muscles is of a different type, the limb is perfectly flexible and remains in whatever position it is put, slowly and gradually falling after some time by the action of gravity. The old experiment of Hunter (Wichmann, op. cif., p. 54) may detect any simulation. Hunter hung a weight to the arm of a supposed cataleptic by means of a tape : the weight drew the limb down very slowly and gi-adually, he suddenly cut the tape, the weight f eU, and the limb flew up 402 ^ SYSTEM OF LEGAL MEDICINE. when the resistance to the voluntaiy contraction was suddenly removed^ showing that the catalepsy was feigned. Charcot [Legons snr les mala- dies du systeme nerveux, vol. iii., p. 17) has demonstrated by means of a registering aj^paratus that if a cataleptic hmb be put in any position it ^vill gTadually fall by the action of gravity, and that the curve of descent will be a perfectly even and regular line. In feigned catale]3sy, however^ the curve of . descent will be very irregular, the limb sinking and then being brought back again by a sudden voluntary effort, showing many oscillations ; the simidator, too, will, after keeping a limb in a given posi- tion mthout support for a certain length of time, give e^ddence of his effort by an increase in the pulse and res]3U'ation. Other forms of spasm are more rarely simulated. The feigning of tonic spasm may be detected in much the same way as the feigning of contractui"e. The various forms of clonic spasm, such as tic, respu*atory spasm, and the like, are to be detected by protracted observation of the patient when he thinks himself unobserved, or by determining whether the affected muscles are such as are normally capable of such action voluntarily. Tremor. — Although tremor is a comparatively common sjonptom of nervous disease, its simulation is not an easy matter. Walton {Jour. Kerv. and Ment. IJis., July, 1890), however, thinks that it can be easily simulated, and says that by resting the hands on a walking-stick or table a tremor of the head may be kept up for a long time without fatigue. Other observers have shown that tremor of the feet or hands can some- times be kept up by supporting some part of the foot or hand against the wall, the bed, or a table. Such obvious methods of feigning should deceive no one. Honig ( Ueier fSumdafmn und Uehertreihung, p. 30) has reported a case where the patient kept up for some time a tremor of the legs by steadying the toes against the foot of the bed, but the tremor at once ceased when the support was taken away. Seeligmiiller {Lehrhucli d. KranTilieiien des RiicJienmarJis, p. 673) has suggested a method for de- tecting feigning in such cases. The patient is put upon his belly and his feet are concealed fi-om his sight ; if he can press the toes against the bedclothes or the foot of the bed he can in tins way keep up a tremor. The legs are then flexed at the knee so that the soles of the feet point upward. In this position Seehgmiiller claims that the tremor will cease and wOl not begin again until the toes can once more be touched to some rough sui^face so as to start it again. A very rough form of tremor, however, can be maintained with difficulty while the feet are in the air, and can be started again without pressing the toes on anything. Such a tremor, however, is manifestly artificial. Real tremor cannot be feigned persistently. After a very short time the rh}d:hm of the tremor becomes ii'regular, the excursions vary very much, and as fatigue comes on the effort to continue the tremor manifests itself in the pidse and respii"ation. Tracings of a simulated tremor would easity show the irregularitj^ Many genuine tremors may cease during sleep, so that such a cessation is of slight diagnostic value. The peculiar tremor of the eyes, nystagmus, cannot be feigned at all. Ataxia, Choreic Movements, etc. — The various disordered move- ments, such as ataxia and chorea, can quite easih^ be feigned, but, when genuine, they are usually associated A\dth definite objective sj'mptoms. A simulator can feign the ataxia and the gait of tabes, but he cannot feign FEiayJW DLSKAISES OF THE MINI) AND NERVOUS SYSTEM. 4o;j the conditiou of tlie pu])ils or the loss of the knee-jerk. The diajL^nosis of any condition will rarely depend upon these symptoms alone, and the only certain method of testing their genuineness is by protracted obser- vation. SENSORY SYMPTOMS. Antesthesia. — The successful feig-ning' of anaesthesia is easy when the i)atieiit can see what he is about and knows that the tests are to be applied. Under such circumstaiuces many persons have nerve enough to permit the cornea or the conjunctiva to be touched without winking, to endure needle-thrusts, strong electrical currents, or even the hot iron. Most schoolboys have driven pins into themselves up to the head with- out any manifestation of pain. It is another matter, however, when the tests are applied unexpectedly. Here, if powerful stimuli be used, the patient will almost invarial)ly start or make some manifestation of sensi- bility. Thus Honig {op. cit, p. 27) observed a simulator who made no manifestation of pain at a deep prick of a needle when he knew that the test was going to be applied ; but the next day, when a needle was stuck into him without his knowing it, he at once made an outcry. In a case of feigned insanity, Field {Jour. Nerv. and Ment. Dis., June, 1890) saw nO' signs of sensibility when he sprinkled cold water on the patient while standing in front of him, but the man started when it was unexpectedly sprinkled on him from behind. Gray [Treatise on Kcrvous and Menfal J>i.se(i.'^f.s, p. 146) has suggested accidentally spilling very hot water on the alleged anaesthetic spot. Pitres' case cited above shows the practical impossibility of feigning auaBsthesia when the tests are applied unex- pectedly. In all cases where the sensibility is to be tested the patient should be blindfolded. If, after the ordinary testing with the tip of a finger or a camel's-hair brush, the patient claims complete anaesthesia, the best test for demonstrating the reality of the autpsthesia is the unexpected applica- tion of a powerful faradic current through a sharp-pointed electrode ; this can be done most easily while testing the ordinary electrical reactions of the muscles. An ordinary testing electrode being attached to one cord of the battery, a pin or a needle may be thrust through the cord between this electrode and the battery, and concealed by the iiand. A large indif- ferent electrode should be attached to the other cord. A faradic battery capable of giving a very strong current should be used. The muscular reactions should be tested with a mild current in the ordinary way, and the patient's attention will thus be distracted from any qui^stion as to his sensibility. While doing this the current can suddenly be turned on to its full strength, and instead of applying the electrode, the pin nuiy be applied to the ana?stlietic spot. The pain of such an application is so great that if it be unexpectedly applied the patient cannot refrain from manifesting his sensation. If the hand or foot be anaesthetic, a pin or some other sharp instrument may lie pressed down under the nail toward the matrix. If the anaesthesia be feigned the malingerer will give some indication of his pain, either by nuiscular contraction, an outcry, or, at any rate, by an increase in the rapidity of the pidse. If the anaesthesia l)e limited to a detiuite ])art of the body it is yv'- sumption in favor of its genuineness if it be limited to a definite periph- 404 ^ SYSTEM OF LEGAL MEDICINE. eral nerve distribution or to the area of any of the spinal segments, since the average simnlator knows too little of such distributions of an- Eesthesia to be likely to feign them. If the boundary between the anaesthesia and the sensitive regions be sharply defined the test becomes easier. The boundary should be marked out mth a colored crayon before the patient is blindfolded. Then, after he is blindfolded, the skin on the sensitive side should be lightly touched at some distance from the line, and the touches repeated, gradually approaching the line, until the patient says he no longer feels them. The point where he ceases to feel the touch should be indicated by a crayon mark of another color, and the test repeated. After a new boundary line has been established in this way, the skin on the ana?s- thetic side of the hue should be touched in the same way, the touches approaching the boundary until a point is reached where the patient says he feels the touch ; this should be marked with a crayon of a third color until a boundar}^ line is again established. If possible, the ]3art should be covered and examination of other parts be undertaken, and these tests be repeated after an interval. If the three lines agree the aufesthesia is undoubtedly genuine, for no one can always say correctly on which side of an imaginary line he is touched, when he is touched close to the line. Some people can tell with considerable accuracy whether a touch is on one side or the other of the median line, but they cannot tell in regard to lines elsewhere, especially the cm-ious boundary lines of the geometri- cal anaesthesias occasionally seen in hysteria or of the anesthesias from a peripheral nerve lesion or from the lesion of a spinal segment. " If this boundary hue pass through one of the less sensitive regions of the skin its genuineness is still more probable, for it is still harder to say on which side of an imaginary line a touch is made in such regions. Bui'ghardt {PraJctische Diagnostih der Simulafionen der GefiiJilsldhnmng, Schwerhorig- Tieit, und Schivachsichfigl-eit) has suggested that when the boundary lines are found to disagree they be shown to the patient and a new test made, but the advantage of this is not apparent. Burghardt has also suggested that the patient be told to indicate by raising the finger whenever he is touched, claiming that, if the touches be rapidly made, the malingerer will sometimes indicate when the anaesthetic region is touched. In most cases, however, it is difficult to get an ordinary patient to lift the finger quickly enough to make tliis test very practical. The compasses may be useful in testing the relative sensibility of two different j>arts of the body, but their use requires very much time, and, as a rnle, the results obtained by them are hardly worth the trouble. Goldscheider has sug- gested another method of testing the genuineness of anaesthesia when its boundary is sharply defined. A ^vire brush electrode or Erb's farado- cutaneous electrode is placed on the boundary line and the faradic cm'reut passed through it. When evenly pressed upon the bod}^ the patient will of course feel the current in the sensitive region, but if it be slightly tipped it may be made to rest almost wholly on the anaesthetic tenitory without the patient observing it has been tijiped. If then he states that he still feels the current the probabilities are tbat his anaesthesia is feigned. In most cases of anaesthesia the skin reflexes are lost or diminished in the affected part. In hysterical conditions, too, some of the reflexes from the mucous membranes may disappear ; a loss of the pharyngeal reflex is especially common. FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM, 405 Wliile these tests are sufficient to demonstrate clearly the genuine- ness of anaesthesia, we cannot always say, if the tests fail, that the an- ajsthesia is feigned ; for in hysteria, as is well known, the boundaries of the anaesthetic region may shift rapidly, and in certain forms of ana'S- thesia the application of electricity is of itself sufficient to change the extent of the anaesthesia, perhaps to diminish it, and in hysterical cases the intluen(,*e of suggestion may sometimes be so great that under ex- amination the auiTestliesia may increase, diminish, or perhaps be trans- ferred to the other side. Fiu-thermore, it is now recognized that hyster- ical ana?sthesia is distinctly of psycliical origin, that the patient actually feels a touch or a prick in the ana?sthetic limb, and that by hypnotism, or in other ways, the patient may be made to state definitely where and how many times he has been touched. All these facts, therefore, must be duly considered before we state positively that an ana?sthesia is feigned. Of other forms of am-esthesia it is not necessary to speak in much detail. The tests already mentioned will reveal any analgesia, which may occur with normal sensibility to touch. Few simulators are likely to know enough to feign thermanaesthesia. If the temperature sense be carefully tested by metal rods of different temperature, according to the method described by Goldscheider {Biagnosfik der Kercexl-mnlJieiten, p. 33), and there be a distinct diminution to either heat or cold in one region as compared with that of the opposite side, the spnptom is very apt to be genuine, although, of course, the success of such a test is not an absolute proof. The unexpected application of very cold or very hot water will usually elicit signs of sensibility if the thermana^sthesia be feigned. Few patients, too, have sufficient knowledge to feign distiu'b- ances of the muscular sense, and, if they should, it is usually possible, on protracted observation, to discover that the patient knows more in regard to the position and the movements of his limbs than he claims. It must be borne in mind that a genuine ana?sthesia can be temporarily produced by the application of belladonna, cocaine, and other drugs. If, however, the area of the anesthesia be extensive, it is not probable that it is caused by the application of such drugs ; for if they were used in amount sufficient to produce ana?sthesia of such an extent, there would, in all probability, be pronounced signs of their physiological action. Pain and Hyperaesthesia. — Since pain is a symptom of almost every disease, and since, moreover, it is a purely subjective symptom, it is not strange that it is one of the chief symptoms complained of by malinger- ers. Of the truth or falsehood of such a complaint we have no absolute method of judging, but in many cases we can find some confirmatory evidence from other symptoms to aid us in forming an opinion. If, for instance, the patient complains of lancinating pains, and Ave find object- ive signs of tabes, or if the pain be referred to a given nerve distribution, and we find VaUeix's tender points or changes in the reflexes, we can assume the pain to be real. In cases, however, where there is no other evidence of disease, we cannot come to a definite conclusion, excepting that if the patient's claim of severe, extreme, and continued pain be true it will often be manifested by disturbed sleep and impaired nutrition. With regard to tenderness, however, Mannkopf and 'Rnm.-pt {CoitralhJ. f. Xervenheill-., No. 12, 1889) have suggested a procedure which often enables us to say definitely that the tenderness is real. If firm pressure be made upon a tender spot, the pain will often cause an increase in the 406 ^ SYSTEM OF LEGAL MEDLCIXE. pulse rate, sometimes as mncli as twenty beats a minute. In some cases, there may be, in addition to, or instead of, an increase in tlie rapidity of tlie pulse, a weakening of tlie pulse, a fiusliing of tbe face, or an outburst of sweat on the forehead. If there be no increase in the pulse, however, we cannot say that there is no tenderness, for in cases of real disease the pulse is sometimes unaffected, especially if the tenderness be slight. In many cases, however, I have been able to demonstrate the reality of ten- derness by this means. It is needless to say that the patient should have no idea of the test to be applied, and it is also better that he should be blindfolded. SPECIAL SENSES. Vision. — The detection of feigned visual distm-bances is a compar- atively easy matter. The feigning of complete blindness of both eyes- demands great perseverance and unusual skill in order to counterfeit the general demeanor of a blind person and the rigid, unaltered look to the eyes, which does not vary at any visual impression. Few have sufficient control to remain unmoved when objects are closely approximated to the eyes. If a large object, however, be suddenly brought before the eyes even of a blind man, the ciu-rent of air engendered by the movement may cause him to make some motion of defense. Sudden and unexpected movements in the neighborhood of one who is feigning blindness, espe- cially threatening movements, may lead him to make some unexpected movement which indicates that he sees. Protracted observation will also show that he has not the characteristic habits of a blind man, and that he is governed by his eyesight when he is moving about a room and thinks himself unobserved. Burghardt {op. cif.) has suggested a method of detecting feigned blind- ness. The patient is asked to put out one finger and then to touch it with the other. A person who is actually blind can do this perfectly well ; the simulator is yery apt to overact the part and not to touch it correctly. Bm-ghardt then had an attendant, with bandaged eyes, do it in the presence of a simulator, and the next day the simulator succeeded in doing it perfectlj^ well. Ai'lt (HeUer, oj). cif., p. 73) has pointed out that in feigned bliudness, if we throw a strong light into the eye so that it strikes the macula, after a time the eye becomes restless and tears be- gin to flow. In such a case we might properly suspect there was percep- tion of light. If, however, this experiment be tried in an eye which has even a slight perception of light, the same effect may be produced, and error maj^ arise. Such experiments, hoM^ever, are seldom necessary. There are very few cases of blindness in wliich the ophthalmoscope wiU not reveal definite structural changes in the optic nerve, the retina, or the conducting media. If the eye be normal in an ophthalmoscopic ex- amination, and if tliei'e be no renal disease, oiu* suspicions may properly be awakened. In a few cases of optic neuritis, or of optic atrophy, blind- ness may precede any changes in the eye itself. Von Graefe (HeUer, op. ('it., p. 73) states that atrophy may occur six months after the cessation of any sensation of light ; but, on the other hand, we see many cases of neuritis and partial atrophy where considerable \asual power is still re- tained, and in cases of atrophy peripheral limitation of the visual field may precede the visible signs in the retina. Heller {op. cit., p. 74) claims that the simulation of unilateral blindness lEiaXEl) DISEASES OF THE MIND AND NERVOUS SYSTEM. 4()7 is miicli more common tlian tliat of complete blindness, as it is naturally much less iniplcasant for the simulator. P^ven in such a case simulation is exceediuii^ly improba.ltlc, since changes would, in all pro])ahility, be found by the ophtlialmosc()[)e in the bUnd eye. If blindness of one eye J^e feig-ned, however, it can usiuilly ha cpiite readily detected by means of prisms or by .siniilar tests. The simi)lest method is that proposed by Von Graef e (Archio f. OpJUh., vol. ii., p. 2()G). The prism, of from six to twelve degrees, with its base turned upward or downward, is placed before the healthy eye. If the lianie of a candle, or a small dot or a fine line upon a paper, be seen douljle, the simulation is at once proven. We may also tr}' whether the double image moves during the rotation of the prism j or whether the -double image disappears upon the reestablishment of binocular vision by turning the base of the jjrism outward. If the simulator be shrewd •enough to know that one of these images belongs to the pretended blind eye, we nuiy hold a prism which refracts vertically before the normal eye .so that its refracted angle will bisect the j)upil. In this way, when the alleged blind eye is covered, monocular diplopia may be produced : if the simulator deny this diplopia, there is good reason to doubt his state- ments ; if he admits it, it can very easily be made into binocular diploj^ia by uncovering the pretended blind eye and moving the prism slightly so that it shall cover the whole pupil. Feigned blindness of one eye can .also be detected by the stereoscope. As is well known, in binocular vision through the stereoscope the fields of the two eyes are united into ■one, Rabl-Riickhard {Deutsche militdr-arztl. Zeitschr., 1874) has recom- mended that we should put into the stereoscope a figure which should have a circle in each field ; in normal vision through the stereoscope the two circles would blend into one, forming a single object, which may .serve as a fixation point. By ai-raugiug the cards so that other figures can be moved about in the field in varying positions, the simulator can readily be led astray, for an object in the right half of the left field will lie on the right side in the common field, and the patient cannot tell whether he sees it with the right eye or mth the left. It must be borne in mind, however, that there are genuine cases of hysterical blindness of one eye, where the patient can really see with the eye that seems to be blind. Pitres (oj). cit., vol. i., p. 103) states that an •oculist once said to him that every case of hysterical Ijlindness was fraud- ulent. Pitres himself demonstrated the plausibilitj' of this by placing a .screen perpendicularly between the two eyes, and holding in front of the patient a card with a line of printed letters. "When the blind (left) eye was closed the patient could see with the right eye only the lettei'S to the right of the screen ; when the right eye Avas closed no letters at aU were perceived ; when both eyes were open the patient could read not only the letters to the right of the screen, but also the letters to the left of the screen, showing conclusively that the letters were perceived with the left eye. This agrees with the conditions which have been spoken of under anaes- thesia, where it has been shown that the patient actually feels a touch in some of the forms of hysterical anaesthesia ; and as this has been demon- strated in many cases where there is no reason to doubt the genuineness of the hysterical symptoms, we niiist consider, as Pitres does, that in hysterical blindness of one eye the blindness exists only with monocular vision. In such cases the other s,ymptoms of hysteria wiU usiuiUy be present, so that we can make an accurate diagnosis. 408 ^ SYSTEM OF LEGAL MEDICIXE. The detection of poor vision is somewhat more difficult. In most cases, however, there are distinct phj'sical conditions in the eye to ac- count for snch vision. Possibly in such conditions there may be some corneal oj^acities, retinitis pigmentosa, etc., or else the failm-e of vision ma}'' be dne to errors of refraction. In the latter case these errors can be readily determined. If the patient makes false statements in regard to the ordinary test with lenses, a degree of refractive erro]-, amonnting from one half to one diopter, can be determined by a skilled observer with an ophthalmoscope, or by the shadow test, if the patient's accom- modation be paral3"zed hy atropine, and refraction errors of less than one diopter cannot have a Y&ry marked effect npon the vision. Hemeralopia is sometimes feigned by soldiers. In examining this condition the patient is made to look into a dark chamber at various objects. By means of a sliding shutter, the chamber can be more and more illnminated, and the degree of light gradually increased until the patient says he can see the objects upon the test-card. A simulator can seldom give consistent and accurate statements. Feigning of color-blindness can usually be detected by the ordinary worsted test. Unless the patient be thorougldy experienced in the mis- takes which the color-blind make, he wiU put together worsteds of colors which no color-blind person woidd confuse. In many cases of alleged defective vision very much can be learned by a careful examination of the field of vision. Various investigations in hysteria and the so-called traumatic neuroses have given added weight to the changes in the visual field. No satisfactory results, howe\'er, can be obtained without a careful investigation by means of the perimeter, and in man}'^ cases the field shoidd be tested not only for form but also for color. If there be hemianopsia there "udll usually be other sj-mptoms to confirm the diagnosis, such as ana?sthesia, paralysis, or the hemiopic pupil reaction. In many forms of disease, including the initial stages of optic atrophy, hysterical amlilyopia, and other affections, there "v^all be a concentric limitation of the field. If the perimeter be placed so that the light comes from behind the patient's back, and the patient be facing a uniform dark sm-f ace, it is impossible for him to feign successfidly the concentric limitation as tested on the perimeter. The outline of a feigned contracted field, as Oppenheun [Vt^eitere Miffheilungeii in Bezug auf die Tranmatisclien Nenrosen, p. 43) has shown, ynR be irregular, and much greater in some meridians than others. Fiu-thermore, on repeated tests the simulator cannot feign the same contraction. Should doubt arise, we may adopt the method suggested by Wilbrand and Saenger ( Ueher Sehsfo)-u)ige)i hei fioictioiiellen Kerrenleiden, p. 189), and test the field by perimeters of different diameters. This renders it practically impossible to simulate I'epeatedly a contracted field which shall lia^'e the same ex- tent and outline. Hearing. — lu the great majority of cases of actual deafness a careful examination of the ear by means of the aui'al specidum will reveal the cause, unless the deafness be due to lesion in the auditory nerve or the labyrinth. Should there be a motive for simidation, and should any changes be found on examination, deafness may usually be detected hy protracted observation. The simulator seldom knows enough to distin- guish between the vibratory sensations Avhich are conveyed to his sense of feeling by loud noises and those which are conveyed to the sense of FEiayEl) niSKASlCS of the mind AXD nervous system. 4(J9 lieariii*;' by tlio same noises, aiul lie will often den}' any sensation \\ijat> ever. The simulator may also start at unexpected noises, and may be aroused t'l-om sleep by a< loud noise, or when drunk or under the influence of an amesthetic he may answer (juestions that are put to him. Heller {op. cit., p. 10,'}) has sng-gested that simulated deaf-diimbness may be detected by a person who is genuinely deaf and dumb, or by a teacher of the deaf and dumb, owing- to the failure of the simulator ac- curately to feign the behavior of a genuine deaf-dumb person. Further- more, if the simulator be uneducated, and attempt to Write, lie will not spell his words correctly, but will l)e ai)t to spell them as they are pro- nounced, whereas the deaf and dunil) person will not be guided by the sound of the word, but will spell it as he has been taught. Absolute deafness, however, is not so likely to be feigned as jiar- tial deafness, and it is a well-known fact that in partial deafness the power of hearing may vary very gi-eatly from time to time. In gen- uine cases of partial deafness there are usually definite changes in the ear. The simulator often fails to imitate the characteristic expression of a deaf person. Casper long ago suggested a method of examination which is of some value. A sentence should be begun in a very loud voice, and the voice gradually loAvered. The simulator will often he con- fused l)y this simple experirneut. Burghardt {op. cit.) has suggested another method of some value. One ear is closed and the patient is put at such a distance that he cannot, as he claims, hear the ordinary spoken voice, the eyes lieing blindfolded ; a tube is put in the affected ear, tlirough whicli the patient can still hear. If How the tube be closed suddenly, without the patient hearing it, and lie still hears the spoken word, he hears it through the air, and his previous statement Avas incorrect. Unilateral deafness is also occasionally feigned. If there are no changes to l)e found in the ear itself, this may be detected in various waj's. Erhardt {Deufaclie miJitUr-in-zt. Zeif.scJu:, 1872) has pointed out that the sound of a repeater may be heard, even when the ear is closed by the finger, at a distance perhaps of ten feet. If the repeater be held six or eight feet in front of the sound ear the patient naturally hears it perfectly well ; if that be closed and it be brought within fom* feet of the ear which is said to be deaf, and the simulator says he no longer hears it, the chances are that his statements are incorrect. The best method of detecting simulation of one-sided deafness, however, is a modification of the experiment described by Coggin {Zeitschr. f. Olwenheilk., vol. viii.). Coggin suggests that the ordinary binaural stethoscope be used. By this means the object is brought rather too near the ears for careful testing, and the experiment should be modified so that the binaural stetho- scope can be used with much longer tubes, the patient sitting several feet away from the testing-object. With tlu^ stethoscope placed in the ears it may then be possible, without the patient's knoM'ledge, to close one or the other of the couducting-tubes; the sound is conve^'cd either to the sound ear or to the alleged deaf ear at the will of the examiner, without the patient's knowledge, and the simulator can in this way be readily led to make contradictory statements. Disturbances of smell and taste are of extremely slight importance, and we have no absolute means of testing them apart fi'om the state- ments of the patient. 410 A SYSTEM OF LEGAL MEDICINE. SPEECH DISTURBANCES. Feigning of speech disturbances is extremely rare. The most com- mon form is the feigning of absohite dumbness. Genuine acquired dumbness occurs only in hysterical mutism, where the patient is un- able to make any sound whatever. In the loss of speech of aphasia the patient makes various inarticulate sounds. True aphasic disturb- ances, such as word-blindness, word-deafness, motor aphasia, and para- phasia demand extreme skill upon the part of the simulator, and in the vast majority of cases they are associated with hemiplegia. Feigned mutism is occasionally seen as one of the symptoms of feigned insanity, but in these cases protracted observation will usually give the opportu- nity for revealing the patient's deception, and lead him into making some unguarded remark. FEIGNED INSANITY. From the old statement of Zacchias, " N-uIIus morhns facUins et fre- quentius simuJari solet qiiam insania,^' to that of Kiilm {ArcMv f. PsycMa- trie, vol. xxii., p. 649), that the number of simulants of insanity are in inverse ratio to the physician's psychiatric knowledge, is a long step, but it shows both the increase in our knowledge of insanity and the change of medical opinion in regard to feigning. Even at the present time, however, although all physicians regard feigned insanity as rare, there is not general harmony as to its absolute frequency. Thus Schiile, in the second edition of his Klimsclie PspcMatrie, stated that he had never seen a case. Fritsch {JahrUicJier f. Psycliiatrie, vol. viii., p. 115) saw but one case out of 3800 in Meynert's clinic, and Moeli ( TJeber irren Verhrecher) and Sander and Richter {Die Beziehungen zivischen Geistesstdrung und Ver- hrechen) have all considered feigning as extremely rare. It may be said, however, that these figures are taken chiefly from the statements in regard to general insane asylums and the ordinary clinics for mental disease ; but Fiirstner {Arch. f. Psych., vol. xix., p. 601) has urged that if statistics were taken from criminal asylums, or from the cases of alleged insanity among criminals, it would be found that feigned insanity was not so very uncommon. Fiirstner himself found 12 cases out of 25. Holmboe (¥orsk Magazin f. Laegevklensk, No. 2, 1893) found 1 case in 21. SneU. {AUg. Zeitschr. f. Psych., vol. xliv., p. 4) considered feigning not rare, and Binswanger (cited by Fiirstner) found 21 cases out of 73. Kiihn {art. dt., p. 650), on the contrary, who had the opportunity of observing over 10,000 criminals, and had investigated nearly 150 cases of insanity occur- Ting among them, saw but two who had simulated. The figures already given from Massachusetts prisons would indicate that feigning of insan- ity by criminals was distinctly rare. It must, however, be again noted that at the Chai-lestown State-prison there were many attempts at feigning, which were readily detected by the prison physician without the need of calling in a special examiner in lunacy. In the vast majority of cases insanity will be simulated only by ih.Q criminal, although Nichols {Boston Med. and Surg. Journal, April, 1891) has reported one case of a boy who .simulated dementia in {\\e hope of obtaining damages on account of a rail- way accident. It must, however, be borne in mind that the percentage of FEW y ED DISEASES OF THE MF\D AND NEll VOL'S SYSTEM. 4]^ actual iusaiiity among criniinals is j)robably much gi-eater than it is in the community at hirge. Not only is the criminal more exposed to the various acquired injurious factors which may produce insanity, but often, as is well known, he is himself degenerate and comes of a bad heredity. Even if we do not accept the theories of Lomljroso that the actucd crim- inal must be regarded as mentally diseased, the evidence in favor of his degeneracy is too great to be absolutely neglected ; and this is often shown, not only in his mental characteristics, but also in many of the physical characteristics. More than one case indeed is upon record where a criminal who already had one form of insanity simulated another form ; and many writers agree with Fritsch that the simulation of mental disturbance is very rarely seen in healthy individuals, and that, in gen- eral, the hypothesis is not unjustifiable that simulation points ^ith some probabihty to a coexisting neuropatliic disposition or psychopathic taint, or that it may be brought into relation with previous conditions of so-called degeneration. Sander and Richter {op. cit.) have called attention to the fact that in •criminals who are actually insane the type of mental disease often shows peculiar mixed forms, which are peculiar as to theii* natm-e and their periodicity, and are mai-ked by ii-regularity and lack of harmony in the symptoms. Frits(;li has pointed out that much may seem simulated wliich really is not so, and cites the case of a young man who was repeatedly arrested for various crimes, who presented a peculiar com- bination of symptoms, characterized, fii'st, by a peculiar gait and ges- ticulations, ^^dth periods of silence, then by various delusions of a hypochondriacal type, which were uot at all in harmony with one another, and gave rise to much suspicion of malingering; yet pro- tracted observation finally showed a distinct underlying condition of paranoia. We must consider, therefore, that even the attempted simu- lation of insanity is rare, and that in few cases, if the physician have any experience, is it ev^er successful. In many cases it is difficult to make an absolute diagnosis of insanity from a single examination, and when there is reason to suspect simulation a period of protracted obser- vation in an asylum may be necessary. From what has ah-eady been said the difficulty of simulation is appar- ent. Krafft-Ebing {Lehvlmcli d. gericlitl. FmchopatlwJoijie, p. 42) has em- phasized this. The simulator is in some respects like an actor : but, unlike an actor, he must be an author as well, and he must also constantly be an im]n'oviser ; his acting, moreover, must be incessant, even if he thinks himself unobserved. A simulator must also act before an audience of trained critics who cannot be diverted from his performance ; conse- quently, he must become exhausted after a few hours, and the mental strain of such a performance may in itself be a cause of mental break- down. The absurd attempts to depict insanity in the majority of novels well sliow the false ideas which are usually held in i-egard to mental diseases. The lunatic, according to popular belief, is either raving or so demented tliat he is incapable of any sensible act or woi-d. In a few cases, of eom'se, tlie simulator may have had the opportunity of associating with the insane and of studying their symptoms with care. In such cases the portrayal of insanity may sometimes be sufficiently Tealistic as to cause considerable doubt as to the actual condition. In ordi- 412 -4 SYSTEM OF LEGAL MEDICINE. nary cases, however, where tliis opportunity for special study is absent^ the simulation is so grossly exaggerated, and so entirely unlike the be- havior of a person who is actually insane, that it can be readily de- tected, the simulator seldom presenting symptoms which correspond to any particular form of insanity. As a rule, the symptoms of simulated insanity begin suddenly, developing upon a period of apparent mental health ; the slight j)rodromal stages, wliich can usually be elicited in ordi- nary cases, are lacking. In most of the attempts at feigning insanity at the Charlestown Prison, the prisoners began by being very noisy and demonstrative, or else, less frequently, they began by some lascivious act, such as exposiu"e of the person. The simulator usually grows worse under examination, and at other times he watches the acts of the physi- cians and attendants in a way which is seldom seen excejjt in some cases of paranoia. He also fears to be too reasonable ; he has no memory of anything ; he is never coherent ; in the c|uiet periods of his insanity he knows nothing ; he manifests no logical reasoning and no association of ideas. The case of a man reported by Krafft-El^ing {Jahrhilcher f. Fsy- cJiiatrie, vol. viii., p. 293) who simulated dementia, deafness, and dumb- ness, shows some of these peculiarities. The patient suddenly became demented, deaf, dumb, and did not react at all to external processes. Previous to that time he had been sane. Such a condition naturally could result ordy from some severe psychical shock or acute brain dis- ease leading to profound mental disorganization, yet, although apparently so demented, he showed himself capable of various acts requiring consid- erable mental power. When given a written order to perform certain acts he responded by writing various letters in a disconnected manner. He had apparently lost all idea of the movements for feeding himself, yet he acquired them at once when shoAvn how to eat. Unlike a dement, he became violent when deprived of food. Another patient, who feigned acute hallucinatory confusional insanity, was apparently ana?sthetic to a X3in-prick when he knew what was being done, but responded when he was unexpected^ pricked. His delirium was not continuous, but he was forced to break off until he could think of new material for his delirium, and fill the interval by singing a song or repeating some stereotyped phrase, and when the symptoms which he at first presented failed to win confidence other symptoms were added. The simulator, moreover, may assume certain symptoms which are suggested to him. A shrewd feigner might naturally be upon his guard if the physician were to make use of the phrase wliich was once advised, that if the patient were insane he would present such and such symp- toms ; but he would often be taken off his guard if the remark be made that such symptoms, if present, would indicate a particular- type of dis- ease ; or if careful in(|uiry were made whether such symptoms, wliicli were characteristic of the disease, were present. Thus, in the case already cited, reported by Tamassia, the jDatient manifested a feeling of cold in the ear, and a lively pain on prei^sure over the left clavicle, on overhearing the remark that in the type of disease which she exhibited those symptoms were always pi-esent ; later, after another suggestion, pressure over the third cervical vertebra caused extension of the great toe. Simulators often manifest a loss of memory, which is so great as to render it practically impossible that it should he real. As a rule, if an insane person can be made to respond to any questions he retains some memory of familiar FEIGNED DISEASES OF THE MIND AXD NERVOUS SYSTEM. 413 facts ; but a simulator whose case was reported by 'Bernardini and Petraz- zani {Rivista sper. ill freniatria, vol. xix., p. GOG) could uot remember his own name or that of his father, did not know in what town he was, was ignorant of the motives for which lie was arrested, and did not recognize persons seen a moment before. One of Fritsch's patients stated that there were six months in the year and three days in the week, that four and five inade six, and tliat three times foiu' were five. Another patient when asked to mention the names of the days of the week left out Tuesday. Wlieu the insane answer questions at all they usually answer with some degree of sense. Thus, if an insane person be asked his age, he may not give a correct answer, but his answer will always have some definite relation to the question put, and not be sometliing entirely differeut. He will never say, as did Derozier (Sj^itzka, Insiuiity, p. 355), "245 francs, 35 centimes, 124 carriages to carry it." Spitzka {op. cit., p. 3o4) has mentioned various special signs which justify suspicion of simulation. The simulator will demonstratively avoid looking the physician in the face, which the patient in stuporous conditions never does. He will give extravagant, absurd answers to simple questions ; he will often be very slow in answering and yet not present the appearances of depressed states. He will be watchful to see whether au observer is approaching. He may recollect his acts and ex- pressions during a feigned epileptic state ; he may make various strange, rhji:limical movements which have no analogy with any form of insanity ; he TLVAj complain more of strange feelings and pain in the head than the insane usually do. He may, if he be clumsy, state that he has delusions, whereas an insane person who really has delusions always states them as absolute facts. It is, moreover, suspicious if the insanity appear im- mediately after a crime. Norman {Bidionary of Psychological Medicine, vol. i., p. 504) thinks that paranoia is very commonly feigned, but the reported cases of feign- ing of paranoia are certainly very few, and to one familiar with the workings of the paranoiac mind the detection of smiulation becomes easy. Few simulators could ever feign the logical reasoning of the paranoiac on the subject of his delusions, his facial expression and actions. His delusions are higlily systematized and worked into every act and thought of his daily life, aud traces of them may be found in hundreds of trivial matters. The shrewdness and logical reasoning by which every event of the day is brought into train with the general ideas of persecution is something that no one is able to counterfeit without unusual opportu- nities for study. In paranoia, too, there will be the history of a bad he- redity or of mental peculiarities beginning in early life and of a gradual development of the symptoms. The feigning of other forms of insanity is distinctly less common. Paretic dementia in its advanced stages presents certain well-known physical signs of the disorder, so that it cannot be shnulated ; but Fiirst- ner {art. cit.) has reported one case of a man wlio had formerly sjient several weeks with a paralytic, Avho feigned the dementia, the dehisions of grandeur, the speech, the uncleanliness, aud even the attacks. Spitzka {op. cit., p. 354) has cited the case of a man who feigned. Avith consider- able skill, the prodromal sjonptoms, and Xornian {art. cit.) has mentioned another case. Fiii'stner {art. cit.) states that most frequently the simulator presents 414 ^ SYSTEM OF LEGAL 2IEDICIXE. the pictiu'e of dementia, ^vitli coexisting apatliY or mutism, or Tvitli strik- ing contradictions of speech, Tri'iting, and actions. Next in fi'eqnency comes a condition of clouding or loss of consciousness, which is claimed to have occurred at the time of the criminal act and is usually accom- panied with hallucinations. In the thii-d group the s^Taptoms are vaii- able, irregular, and confused. The foui-th group presents conditions of excitement, with confused, senseless utterances, and a tendency to ^dolent acts. All these forms, however, present sjTnptoms not unlike those seen in acute hallucinatory confusional insanity {Acute liallucinaiorisclie Ver- iviyrtJieif, Amentia of Meynert), the form of insanity which prohably is the least readily recognized by ahenists in this countiy. In this form of insanity the simulator usually misses the pecuhar confused condi- tion. He is too incoherent, and does not manifest the occasional intelli- gent association of ideas seen in these confused states; he does not give the sensible answers wliich patients can sometimes be roused into gi^dng. Such j)atients, moreover, will often manifest sense enough to answer in regard to familiar matters of life, to tell theii' name, to re- member people, to state the days of the week, to count, or to do simple sums. Most cases of this condition, too, show distinct physical changes, a sluggish ch'culation, cold and congested extremities, and a marked loss of weight ; they also show occasional ^dolent outbiu^sts and distinct de- lusions. In all the acute psychoses there are usually distinct physical conditions coexisting with the mental disease which point definitely to a morbid state, such as the increased pulse, insomnia, loss of appetite, loss in weight, defective cii'culation, and various conditions of the skin, especially cold- ness and cyanosis. The simulator will sometimes cease his actions if he tliinks himself unobserved. A simulator at Charlestown was extremely noisy when anybody was about, but he was very quiet when he supposed the officers were out of hearing. Occasionally the simulator will not go far enough. In a case of in- sanity simulated by a young woman at the Suffolk County House of Correction, communicated to me by Dr. Fisher, conditions of dementia and mania were feigned. The patient finally became extremely noisy and demonstrative, and tore all her clothing to pieces, and was found in her cell stark naked ; yet, when the officers came to the cell, she tuimed her back to them, which no maniac as ^•iolent as that would have done. In rare cases, especially where the simulator has had opportunities for studjdng or observing insanity, tlie s kill in feigning is sometimes extremely great, and shows wonderful powers of endiu-ance. A simu- lator at the Suffolk County House of Correction went so far as to daub himself and his cell "with excrement, and finally to eat his own fa?ces. In regard to the feigning of the different t}^3es of insanity the forms which can be most successfuUy feigned are those which present the t^'pe of apathy and dementia. Snell {art. cit.) claims that if a person can remain absolutely mute it becomes exceedingly difficult to unmask his feigning. Field {art. cit.) has reported such a case, where a man for weeks would not utter a word. Careful observation failed to show that he moved during the night, and in passing through a low doorway he would strike his head unless the attendants took pains to push the head down low enough for him to go under. In this way he received several pretty severe blows. He would not take food, even if it were left beside FEIGNED DISEASES OF THE 2IIND AND NERVOUS SYSTEM. 415 liim, altliougli lie would swallow wlien food was put into liis mouth. He did, liovvever, respond when cold water was sprinkled upon him unex- l)e<'ted]y, and he finally es(;aped from the prison. One of his fellow-pi-is- oners afterward eonfessed that the man talked with him, and occasionally moved about when he knew no one was near. It may be possible to simulate the slight excitement of simple mania or the slight depression of simple melancholia, or convalescence from these conditions, with a certain amount of success ; but no patient has the i)hysical endurance to feign the excitement and violent actions of ordinary mania, and although he can assume incoherence for a time, he cannot keep up the incessant flow of incoherent plirases ; after a time nature must assert itself and fatigue ^^dll be manifested. Insomnia, rapid loss of weight, and loss of appetite, are aU beyond his control. The same may be said of the feigning of acute melancholia. Although for a time he may assume the depression, he cannot keep up the psychical anaesthesia, the profound depression, the manifestations of gi'ief, the self- absorption ; nor can he feign the insomnia, the cold and clammy extrem- ities, the weak ]3ulse, the loss of appetite, the constipation, and the various other physical symptoms so often seen. In conclusion, it may be said that in the majority of cases where simu- lation is suspected there may be sjrmptoms present upon examination which will prove that our suspicions are in part groundless ; but it must also be borne in mind that the failui*e to find such symptoms as have already been described, or even the detection of sjonptoms which are apparently contradictory, is not absolute proof that the disorder is simulated. BIRTH, SEX, PREGNANCY, AND DELIVERY. BY ANDEEW F. CUEEIER, M.D. I. BIRTH, Legal OWgation of Physicians ivith Reference to the Recording of Births — JDetermination of the Period of Development in Xeic-horii Infants, e^speciaUy in the Still-born, with Evidence Relating to the Yiahility of the Latter. The importance of correct and accurate vital statistics both to the lawyer and tlie physician is self-e^^dent. Indeed it is a matter in which the entire commnnity is interested, for in tlie absence of accurate records of this character how can the status of a community as to population be ascertained f But there are other considerations which are of much 'greater significance in this conuection — considerations which affect the material welfare of large luimbers of individuals, and which depend in no small degree upon the faithfulness with which these records are made. The responsibility of physicians is, therefore, direct and decided in this matter, and should be appreciated from the very beginniug of their career. The state rather than the church shoidd be the custodian of such records, at any rate in so far as the material interests of the individual ai-e con- cerned. The recognition of this fact has doubtless been ai) important factor in the formation and development of bureaus of vital statistics in connection with the systematic regulation of all matters which pertain to the public hygiene. One of the decided evidences of ad\^ancino- civili- zation consists in the very general establishment of boards of health, and the development of sanitary science in all parts of the world. "With in- creasing experience the work of such bodies is yearly becoming more perfect and valuable. It will continue in this direction, pari passu, with the importance which physicians attach to it. and the heartiness and iu- telhgence of then- cooperation. In New York the law requii-es the return of a birth-certificate to the local board of health or other offieial keeper of records within ten days after the birth of every child, whether alive or dead at birth ; and a penalty of ten dollars attaches to neglect to fulfiU this requirement. This is the duty of the physician if he were in attendance at a given birth ; otherwise the return must be nuide by the midwife or other person who assisted when the birth took place. The im]iortauce of this subject should be emphasized bv those who serve as instructors in 417 418 ^ SYSTEM OF LEGAL MEDICLNE. medical colleges, and in the examinations whicli candidates for license to practice are compelled to pass. In France the following sections from the Civil Code appertain to the registry of bii'ths : " Art. 55. Declarations of birth mnst be made within three days of accouchement to the proper civil of&cer ; the child shall be shown to him. " Art. 56. The bii-th of a child shall be declared by its father, or, in default of the father, b}^ the physician, surgeon, midwife, officer of health, or other person who assisted at the accouchement, and if the mother were confined away from her own home by the person at whose house she wa& delivered. The fact of the bii'th shall be stated in proper legal form in the presence of two witnesses. " Art. 57. The return of a birth shall specify the day, hour, and place of birth, the sex of the child and the names he has received, the fii'st and second names, occupation, and residence of the father, mother, and wit- nesses." " Penal Code, Art, 34:6. Every person assisting at an accouchement who shall fail to make the declaration as prescribed in ^t. 56 of the Civil Code and in Art. 55 of the same Code shall be punished by impris- onment of from six days to six months and by a fine of from 16 to 300 francs." The father or head of the house must report the birth if present at the time ; otherwise upon the physician, if one were present, devolves this obligation, if he assisted efficiently in the accouchement. The duty devolves upon him though the child is born upon his arrival, if it is still united by the cord to its mother and the placenta is still in utero or in vagina. The same obligation holds for still-born infants if they have passed the fourth month of fetal life. (Vibert, Precis de Medecine Legale, Paris, 1886, p. 645.) The determination of the period of development which has been reached by a new-born infant, whether it is matiu-e or premature, whether it was living and viable at birth, are all matters of the greatest importance, and can usually be decided mth a considerable degree of precision. These subjects are elaborated in the article upon Infanticide (q.v.). n. SEX. Hermaphrodism — Defective and Rudlmentcn'i/ Organs of the Genital Ap- paratus, and the Bearing of the same upon Matrimony and Fertilitif — Determination of Sex — Pntertij and its Attendant Phenomena — ■ Menstruation, Normal and Abnormal — The Menopause, Hermaphrodism or hermaphroditism is a condition which has elicited a great deal of attention from the earliest times and has given rise to a great variety of opinions and speculation. The work of Klebs upon this subject is scholar!}'- and rational, but that of Pozzi in his Traite de Gyne- cologie, vol. ii., p. 1069, is more recent, and will be frequently referred to in this article. To go to the root of the matter in defining the term, we mnst have in a true hermaphrodite, as Pozzi correctly states, a being who has the genital organs of both sexes, with the possibiHty of functional activity of both sets of organs. The testicles and ovaries are the essen- tial organs of reproduction in the male and female sexes respectively. liiJiTH, >sjcx, rRijaxAycY, and delivery. a\\) A true Iic'i'iiuiplirodite must have orji^ans with the aimtoiuu^al i)e(Miliai-i- ties of botli ovaries and testicles. Pozzi deehires that there does not exist a single incontestable example in which this condition has been realized; but lie, as well as Klebs, has evidently overlooked the case of Heppner (quoted by Garrigiies in Mann's iSt/.sfein of Gj/Hf'coIof/i/, vol. i., j). 2G9), which w.is that of a child which died at the age of two months and was fonud by post-mortem exanunatiou to have a hyi)ospadiac penis or enlarged clitoris, a cleft scrotum, a sinus urogenitalis and Kosenniiilici-'s organ representing parovarium and epididymis, a prostate gland, lioth testicles, vagina, uterus, Fallo})ian tubes, both ovaries, I'ound and 1)road ligaments. The ovaries contained Gi-aafian follicles with ova, and the testicles had seminal canals. Among plants and many of the lower orders of invertebrate animals the condition of true hermaphrodism is common enough. Bland Sutton states {Tra»s/ua)i(h'fs and (nidrof/i/ns,. according as the peculiarities of the female or the male sex predominate. In gyiMndei's there may be menstruation, Avell-developed manima^, uterus and ovaries, aud the possibility of impregnation. In (i)idro(j>fns menstru- ation is absent, the breasts ai;e of the male type, uterus and ovaries are absent, and there is a possibility that they ma}^ beget offspring. In both * Plenty of cases ai'e recorded in legal and medical literature as veritable instances of liermai)lirodism. Lukomsky's case (quoted by R. Guiteras in Morrow's >'ost mortem. The same s])ecinien was examined by J. B. 8. Jackson, wlio found no trace of the os externum uteri, no vaginal portion of the cervix uteri, and a vagina only 420 ^ SYSTEM OF LEGAL MEDICIXE. varieties tlie individual may act as the male or female agent in copnla- tion, and it may be impossible to determine tbe sex without abdominal operation or post-mortem examination. In gijnanders the cHtoris may be so much enlarged as to serve ^\- the fmietional pui-pose of the penis; in androgt/ns the penis may be very smaU, the scrotum bihd, and the opening of the ure- thra so large as to admit the penis in the copulative act. The ac- compaupng figiu-es from Pozzi's work show the difficulties which ~^^ - t , --• may be encountered in attempt- ing to determine the sex in such cases. Hermaphrodites, of which- ever variety, are probaldy al)le to beget and bear offspring, at least Fig. 60.— c. Clitoris: h, connecting bridge from Fig. 61.— e. Clitoris; or, orifieium clitori.-i to meatus tirinarius ; mu, meatus urinaritis ; or, vaginee. (Pozzi. ) oriflcium vaginae. (Pozzi.) in some cases, but the common observation is that they are sterile ; in fact but two cases occur to the wiiter in the literatm-e of the subject in four or five lines in eii-cumference. Xo true ovarian stmetui'e was found. The testi- cles -were normal in size and structure, but there -v^-ere no vasa deferentia, vesiculis seminales, or prostate gland. Among recently reported cases may be mentioned one of Mr. Edgar "Willett's, reported at the meeting of the London Pathological Society, February 6, 1894. The specimens presented -were from a man who died, at the age of forty-foiu-, of cerebral hemorrhage. The testicles were undescended ; there was a well-developed uterus and vagina ; the sexual glands, though occupying the situation of the ovaries, proved on microscopical examination to be the testicles, the membrana propria of the tubuli being very thick. There was a tunica vaginalis on either side of the scrotum, and the penis" was well developed. The man wore a beard, was married, and had two children. The testicles were pro^-ided with vasa deferentia. which passed down by the side of the vagina toward the prostatic di^•ision of the urethra. The vagina nar- rowed as it perforated the prostate gland, and opened in the usual sittiation of the uterus maseulinus. A closed Fallopian tube proceeded from the uterus on either side, terminating above the globus major of the epididraiis in a body representing the nsual hydatid of Morgagni. 'Mx. Stonham reported a similar case to the society a few years ago. BIRTH, SEX, PREGNANCY, AND DELIVERY. 421 wliieli tliey were observed to be fertile. (Cases are reported in which lierinaphrodites have discharged semeu containing' living sjjerinatozoa, while others have had ovaries in which were Crraaiian follicles and ova.) They must necessarily hold a peculiar position before the law. Their right of holding property and voting might be called in question. If the}^ mar- ried the marriage might be annulled on account of their i^hysical defects, and yet the law does not f orl)id their man-ying. They may have inordinate or defective sexual desire. In the cases which one finds recorded, those wlio resemble females are in some instances excessively libidinous. This may be due to the exul)erance of erectile tissue in the preteruaturally enlarged clitoris, and the irritation to which that sensitive organ is continually exposed. In those who resemble males, on the other hand, an aversion to women and to the sexual act is sometimes reported. The absence of well-marked peculiarities which are common in the physical development •of well-formed specimens of either sex is to be expected in individuals of such doubtful or bleuded sex as are hermaphrodites, but one does not see, in actual exj^erience, the grotesque characteristics viith which -smters have been prone to clothe these unfortunates. One should not expect to find, on the one hand, a strong voice and a manly beard, or, on the other, well-rounded limbs and womaidy breasts — these are the attributes of persons who are not physically defective; but one may sometimes see individuals with imperfect generative organs of one sex and well-marked peculiarities of figure and habit of the other. The precise determination of the sex in such cases is not easy. Hermaphrodites are not the onty ones who possess peculiarities of the genital organs, but such j^ecidiari- ties are often their chief distinguishing feature, and the,y will now be considered in detail, together mth similar or related peculiarities in individuals al)out whom the sex is not doubtful. The genital organs of the male are the penis and scrotum externally, the latter containing the testicles with their appendages, the epididy- mides, and the spermatic cords, which connect the testicles with the .seminal vesicles, the latter lying at the base of the bladder and serving as reservoirs for the semen. This fluid is conveyed from the testicles, where it is secreted, through the vas deferens, a tube contained in the spermatic cord, to the seminal vesicle, whence it is discharged in the act ■of copulation into a short tnhe called the ejacidatory duet, and thence into the urethra, the canal which extends through the entire length of the penis, terminating in the bladder, the reservoir of the urine. The penis is joined to the bladder by a trilobate structure called the prostate gland, through which the urethra passes, terminating in the bladder. The minute anatomy of these structures is not essential in this connec- tion. The testicles are developed in the early months of fetal life on either side of the lower (lumbar) segment of the spinal column, from which position they gradually descend into the pelvis or bony basin which connects the body or trunk with the lower limbs. During the seventh month each testicle leaves the pelvis, passing do"\vn a canal in the anterior and lowermost portion of the al^domen kno^^Ti as the in- giiinal canal, and by the end of the eighth month it has reached its final destination in the scrotum. In the female the external structures are the mons Veneris, which is composed mainly of fat, with its appropriate external coverings (skin and liair), and the labia majora, the latter presenting an elliptical appeal'- 422 A SYSTEM OF LEGAL MEDICINE. ance, tying imder tlie mons Veneris and being partly concealed from view on account of tlie inclination of tlie pelvis when a woman is in the erect position. Within the depression at the inner aspect of the labia majora and including its upper two thirds are the labia minora or nymphse, and at their apex is the clitoris. Below the clitoris is the opening of the ni*ethra, the lat- ter terminating in the bladder^ and below this opening the entrance or introitus of the va- gina, which in the vii'gin is usu- ally shielded by a membranous structure, the hymen. The va- gina is a tube about three inches long which terminates in the uterus or womb, a portion of its necli being within the vagina, while the remainder of the necTi and the entire hody are above the vagina and in the cavity of the pelvis. The uterus is pear- shaped, and from each upper corner or horn extends a cylin- drical tube three and a half inches long, the Fallopian tube,, terminating in a beautifully fringed extremity. Below each tube, and attached to its inner or uterine end by a ligament an inch or an inch and a half long, is the ovary, an ovoid strncture about as large normally as a small English walnut. It is also attached to the fringed extrem- ity of the tube by a single stalk or pedicle of very delicate struc- ture. As an ovum matures in the ovary, its envelope, the Graafian follicle, swells, and, when it ruptures, the ovum is grasped by the fringe or ten- tacles of the tube, like the ten- tacles of a sea-polyp, and car- ried forward into and along the tube, the cilia of the epithelium with which the tube is lined pushing it along until it reaches the uterus. On its way through the tube or within the uterus it is met by the spermatozoon, union of the two elements and conception taking place ; or if this does not occur the ovum is cast out of the uterus as inert matter. The penis may be abnormally large or abnormally small. It may be so smaU as to simulate an enlarged clitoris and perhaps cause uncertainty ■^ ^■A: ^' I Fig. 63.— Example of hermaphrodism. (Pozzi.) c, Clitoris. r.lRTII, SEX, ritEGNANCY, AND DELIVEUY. 423 as to the sex of the iiulivithial. If the or^-un in question has a canal and this canal terniiiiates in tlie bladder, the or^uii niust he a penis and tlio individual a male, no matter what other defects may exist. An imper- fect urethra with an opening on the lower surface of the penis (hypo- Fig. 63.— p, Hypospadic penis; s, symphysis pubis; t, testicle; i\ bladder; v.p, pseudovagina; 7', rectum. spadias), or on the upper surface (epispadias), or on the skin (perineum) between the scrotum and the anus, is a common deformity in hermaph- rodites and in some in whom there is no doubt in regard to sex. Such a deformity often prevents fruitful sexual intercourse. Absence of the penis may result from disease or injury ; congenital absence of the organ is of very rare occurrence. The scrotum may be cleft or bifid, suggesting the labia majora of the female, and this is common in hermaphrodites. It may be empty, that is, without testicles, or it may have a single testi- cle, neither of them, or only one, having descended during fetal life. It may have a smooth surface like the lal)ia majora, or the wrinkles and creases which are normal to it. The development of the testicles may have been arrested, or they may have withered (atrophied) and disap- peared. If the testicles have descended only partially they may be fomid thus dislocated post mortem, and gi^"e rise to uncertainty as to whether they are ovaries or testicles. Absence of the testicles may be due to disease or injury. In eunuchs the testicles alone may have been removed, or the testicles and penis. Disease of the other organs of the male gcniito-urinary apparatus may have an important bearing upon the question of i)rocreative power and sexual capacity, though it might not cause difficulty in the detin-mination of sex. In the feiiiale the appi^arance of the labia majora might suggest a defective scrotum, especially if one or both ovaries had descended into 424 A SYSTEM OF LEGAL MEDICINE. tliem ; au accident wliicli has sometimes occmTed, tliougli in an extensive experience during many years the writer has never seen it. The clitoris is normally half an inch to an inch in length, only its minnte extremity being nsnally visible, bnt it may be enlarged to a length of three, four,, or even five inches. (See Wharton and Stille, vol. iii., p. 143.) It is sus- ceptible of erection, and when gTcatly enlarged may perform the same function as the penis in the copulative act ; but it has no canal, or if an abnormal canal exists it does not terminate in the bladder. The labia minora may be small and inconspicuous — in hermaphrodites they may be rudimentary — esjDecially if the chtoris is greatly enlarged. In adult life they may become large and prominent ; in the Hottentots they are enor- mously enlarged and jjendent. They are often enlarged as the result of masturbation, and sometimes as the result of venereal disease.* The urethra, normally of small caliber, and about an inch long, is Fig. 64.— Author's case, representing enlargement of labia minora. * The accompanying figure represents a rare case of this character which has been- Tmder the writer's care. The patient is a large, well-deA'eloped woman, twenty-four years of age, a prostitute, a syphilitic for three years, an opium-smoker for a year. The tumor has existed a year and a half, is painless, and does not prevent sexual intercourse. After endeavoring ineffectually to reduce its size by means of anti- syphilitic drugs it was entirely removed with the red-hot cautery-knife. BIllTU, HEX, ritEGXAXCY, AND DELIVERY. 425 susceptible of considerable dilatation. In henna])lii-odites and those who were otherwise deformed, it has sometimes been mistaken for the vagina and has been nsed in the eopidative act, of course to the great detriment of tlie individual. The hymen may be rudimentary and present no obstruction to coitus, or ii> may be so thick and firm that coitus will l)e impos.si1)le until it has been incised or entirely removed. In such cases serious difficulty may Fig. 63.— Figure representing tlie female organs of generation. (D. Ber^-y Hart.) F, Ovarv: G, par ovarium; Jf, round ligament ; 0, broad ligament; N, entrance to vagina; J/, labium minus; K, labium majus; M, clitoris: P, vagina; ^-i, os uteri; J3, body of uterus; C, fundus uteri; A Fallopian tube; £, fimbriated extremity of tube. arise on account of the retention of the menstrual fluid. A large ab- dominal tumor may thus be formed, and the issue may l)e a fatal one. The vagina may be rudimentary or entirely wanting.* If tlie vagina is imdimentary it is often possible that it may be so developed as to accom- plish all the necessary functional purposes. The uterus is seldom entirely wanting. I. E. Taylor has reported two cases in whicih x)ost-mortem examination revealed no trace of the organ. It is very frequently rudimentary. Peaslee has reported a case in which it was a mere band of tissue of no functional importance. (Mann's Sijstem of Gi/nerologi/, vol. i., p. 269, quoted by Garrigues.) The writer has seen many cases in which it was very smaU and insignificant. In hermaphrodites it is usually rudimentary. Such a condition may * An interesting case of tliis character -n-as imder the wi-iter's care recently. The patient was a girl, sixteen years old, with no vagina, all the other organs being well developed. Inability to discharge the menstrual fluid had led to tlie formation of a large abdominal tumor. Tliis Avas opened and evacuated tlirough the rectum. A false opening was then made where the vagina should have been, but after two months her pliysician unfortunately allowed it to close. The menstrual fluid then reaccumnlated, and tlie writer foimd it necessary to open the abdomen and remove tlie ovaries, thus bringing menstruation to an end. In view of tlie possiVnlity of matrimony a vagina was tlien made by cutting, tearing, and dilating, the operation requiring several montlis for its completion. This vagina miglit serve the purpose of copulation, but could not be expected to answer for the safe passage of a fetus ; hence the necessity of sterilizing the patient to anticipate a possible calamity. The patient was at last accounts entirely well. 426 ^ SYSTEM OF LEGAL MEDICINE. effectually prevent impreguatiou, but it is astonisMug to "wliat an extent sucli an organ maj" be de^elojjed by suitable gynecological treatment or by the stimulus of coitus. If impregnation takes T)lace serious results may oceui*, on account of the imperfect character of tlie tissue ; either abortion or ruptiu-e of the organ, usuall}^ with fatal resTilt, being the consequence. The Falloj)ian tubes are essential organs in the female reproductive apparatus, forming the only medium of communication between the uterus and the ovaries, and unless they are in proper func- tional and structural condition the jjassage of ova to the uterus and the accomplishment of impregnation become impossible. The tubes are not essential to menstruation, as some writers have affirmed, for menstrua- tion has been kno^^'n to continue after they have been removed, more or less of the ovarian structui*e having been retained. Then* importance as ■oviducts is supreme, and for this function there can be no substitute. They may be rudimentary, mere imj)ervious cords, and they are suscep- tible of various forms of disease at all periods of life. Disease of the tubes may be cm-able spontaneousl}' or as the result of siu-gical treat- ment, or it may be incurable. It may be of a malignant character (sar- coma, carcinoma), or inflammatory, the result of gonorrhea, abortion, or labor at term ; it may be due to infection from unclean hands or instru- ments, the infectious pro'cess having extended from the vagina or uterus ; or it may be an element in an infectious disease such as tuberculosis or syphilis. In the great majority of cases the disease is due to gonorrhea or abortion, the ultimate cause being an infective bacterium. It is one of the most common forms of disease peculiar to women, and its im- 23ortance in a medico-legal sense, especially with reference to the respon- sibility of the gynecologist in its recognition and treatment, is gTcat. It has heretofore escaped recognition in medico-legal works, principally for the reason that until very recentty correct knowledge of the subject was possessed hj yery few. In hermaphrodites the Fallopian tubes are often wanting or rudimentarj' . The ovaries are the distinguisliing sexual organs of the female as the testicles are of the male, and the absence of them renders the individual absolutel}' incapable of conception. The}' control the function of o^iila- tiou and have a ver}' decided influence upon menstruation. In cases in which they have been removed menstruation usually ceases at once or within a short time, but it has been known to continue for many months after their removal, thus supporting the statement of Aithur Johnstone that the menstrual function is controlled by a nerve in the broad liga- ment contiguous to the uterus, and that this nerve has not been cut when the ovaries are removed should menstruation persist. The ovaries may be congenitally absent or they may be very smaU and defective in struct- lu'e. Like the FaUopian tubes, they are extremely susceptible to dis- ease, and the disease may begin in fetal life or it may be deferi'ed until advanced age. Tliere is perhaps no organ of the body which is sulgect to disease in a gi-eater variety of forms, and perhaps none Avhich is at- tacked more frequentty. It fm-ther resembles disease 6t the FaUopian tubes in that it nuiy be recovered from spontaneously, it may make the patient an invalid for life, it may be fatal -without a timely surgical operation, or it may be inevitably fatal in spite of any form of treat- ment. Disease of the ovary may be independent of disease in any other organ, or it may be an extension of disease in the tubes. It is the gloay BIRTH, SEX, ritEG NANCY, AND DKLllERY. 427 of modern g'ynecological surgery that it lias found a remedy for the disease in thousands of eases whieli formerly were doomed to certain deatli. The medi(M)-h*g'aI importance of ovarian disease, like that of tubal disease, has but lately Ijcen re(!Ognized. In herinaphrodites (^ues- ti(ms relatin*^' to the ovaries are always of g-reat significance, and the sex of an individual under consideration may require for its determination ill! abdominal operation, inspection of the jielvit; organs, and differentia- tion with the aid of the microscope of ovaries from testicles. Unde- scended testicles inay be mistaken by outward examination of the body for ovaricis, the general contour of the person's frame and the appearance of the external genitals may still leave one in doul)t as to the (juestion of sex, but the structure of tlie organ as revealed l)y the microscope will usuaily set doubt at rest.* l*ozzi has analyzed three remarkable biases reported by ex(^eileut (jrerman authorities, which were regarded as illustrations of the coexistence in the same person of testicles and ovaries. He concludes that the propositions advanced have not been proved. The condition of the breasts in Iiermaphrodites or those who are of doubtful sex may prove of great value in deciding the question of sex. In some cases in which the external genitals are of the female type, the breasts will be fiat, the nipple poorly developed, and the mammary gland rudimentary. This has been the history in a numl)er of recorded cases of hermaphrodites of gijiudide)- variety, but other cases are recorded in which the reseml)lance to the female type of breast is unmistakaljle.t In recent years, that is, since the era of abdominal surgeiy began, and in which the numl>er of operations upon the essential organs of genera- tion in the female has multiplied, fewer cases of doubtful sex have been reported. Should they be necessary, exploratory operations may be resorted to in cases of doul^tful sex, without waiting for the decision of the post-mortem table. The l)earing of the foregoing pages upon the questions of fertility and matrimony is direct and impoi-tant. Marriage being a contract in the eye of the law, and one which may be dissolved under certain adequate conditions, it follows that both parties to the contract have a right to know beforehand whether each is in such physical condition that the marriage relation can be properly consummated. It is assumed that such knowledge is lawful, Ijecause a divorce is granted in cases in which physical defects prevent the consummation of the marriage relation. The family is the unit in civilized society ; it is essential to the stability of society that the propagation of species should be effected under the safeguards of the family ; the love of offspring is innate, and should be encouraged within reasonable limits, and is one of the bulwarks of society : therefore, whatever our views as to the morality or immorality of divorce may be, we must admit that society can protect itself only * The writer is aware that Zweifel has stated that tlie ovary and testicle in early iiifaiiey closely reseiuhle each otlier in tlieir anatomical structure, and that differen- tiation of them may be an extremely difficult and delicate task. (Pozzi, loe. cit., p. 1079.) t In Von Franquc's case (quoted by Garrigues, IMann's Sjistem of Gi/iiecnlogi/, p. 209 et seq.), the individual whose picture is given lias a strongly marked female face, broad liips and back, long hair, and finely developed breasts. She lived as a woman until her forty-sixth year; tlien, as the male organ of copulation was strongly devel- oped, and as a whitish fluid was discharged from it during coitus, she assumed male .attire, married, and lived as a man the rest of lier life. 428 ^ SYSTEM OF LEGAL MEDICINE. by the marriage of men and women in whom the reproductive ap- paratus is not impotent. This is fundamental for society at large, and if true for the mass it should be true for the individual. But absence of otfsjjring does not necessarily imply absolute impotence or even defect of the reproductive apjjaratus in either a husband or a wife ; all the organs may be structurally sufficient for the projjer performance of copu- lation, the desire for offspring ma}^ be intense, and yet the desire is not gratified. It has often happened that in some of these cases the adop- tion of suitable medical or surgical measures brings the desired end ; in others the husband or wife, by marriage with some other person, demon- strates by the presence of offspring after a suitable period the fact of his or her ability to beget or to conceive. Divorce in such cases must be for some other cause than physical defect, otherwise husband or wife might be the victim of grave injustice. What, then, are the conditions j)ertaining to the reproductive apparatus which render marriage invalid because necessarily infertile? Plainly, the absence of those organs which are essential to the marriage act and to the begetting or bearing of offspring. A man who was without testicles at the time of his mar- riage would be absolutely unable to beget offspring. But a man without a penis, mth one which is rudunentary, or with only a stump resulting- from disease or injury, may accomplish the sexual act, though imper- fectly, and may beget offspring. It woidd therefore be a question whether a woman whom he may have married could seciu'e a divorce from him on the ground of his impei'fection.* Eunuchs are incapable of begetting offspring because deprived of testicles. This does not signify that they are always without sexual desii-e, and it is said that in cases in which the penis has not been removed the sexual act is not unusual. If a female is without a vagina sexual intercourse and conception are both impossible, though all the other genital organs are j)resent and well developed. If in such a case the abdomen were opened, the uterus,. ovaries, and tubes found well developed and without apparent disease, and a pseudovagina were made, conception might be possible and no ground for divorce for absolute deformity be tenable ; though it might be m*ged with justice that the woman was physically defective, for the delivery of a full-term child \)y such an unnatural passage, if possible at all, would almost certainly result in the death of the mother and proba- bly in that of the child as well. The only alternative to this hazardous method of delivery would be the Cesarean section. Readily as such operations ma}^ now be performed, and willing as the writer would be on all suitable occasions to perform them, he would in no instance feel justified, nor deem it justifiable in another, to deliberate^ bring about by operation upon a woman such conditions as would expose her to such great risk to her life. There are many women who express a willing- ness to take such a risk, or any other which would offer to them the * A case in point is that of a man of robnst physical development and defective moral sense, who copulated not only with his wife but with numerous other women. Cancer attacked his penis and it was ami>utated, only a stump of insignificant propor- tions remaining. His sexual appetite remained, and he continued to liave indiscrim- inate sexual intercom-se. He stated upon inquiry that none of the women with whom he cohabited experienced any difference of sensation at the change in liis condition. Whether any of the women were impregnated after his operation is not known, but the essential elements in his proereative power were said to have remained. BIRTH, .^EX, I'REGNANCY, AMJ DELIVERY. 420 possiljility of maternity, so strong- is the maternal sense \vitli some women ; but the writer must leave to others the cooperation in all such eases, which to his mind is entirely unwarrantable. The vagina may be normal and coitus be readily accomplished, but if the uterus is al)sent or extremely rudimentary, conception will be impossible. The condition of the uterus can usually be ascei'tained by a carefid exaniinati(jn, especially if the tissues are thoroughly relaxed by the administration of an auics- thetic. In some cases a decision can be reached only l)y in(dsion of tlie abdomen and direct inspection of the pelvic organs. In hundreds of cases the uterus has been removed for serious disease, the disease being of such a character as to render conception improbable or impossible. It has freqiTcntly been successfully removed by the ^^^L■iter under such conditions. Absence or rudimentary condition of the Fallopain tubes render.s- conception impossible. Such a condition resulting from congenital fault is rare, but disease of these organs not infrequently occurs before marriage, rendering the woman hojielessly sterile, and the situation is equivalent to that in which they have been removed by the surgeon's- knife. Absence or rudimentary condition of the ovaries places a woman in a condition similar to that w^hich obtains when the tubes are absent or rudimentary. Disease in the tubes and the ovaries very often coexists, and a condition which demands removal of the tubes demands equally the removal of the ovaries. There is no law which forljids hermaphro- dites to marr}^, but as marriage with such individuals is ahnost certain to be unfruitful and result in discontent and unhappiness, and as, more- over, there is in most cases legal ground for divorce, such unions are alwaj'S to be discoiu'aged. The period which is known as that of puberty marks one of the most important and critical eras in the life of every individual, whether male or female. The changes which then take place are marked and promi- nent, and are indicative of a decided transformation in the physical con- dition. Ripeness of intellectual faculties, however, is no feature of this period, though it has been stated that in the negro race, at least as that race has been observed in this countrj^, quickness of perception reaches its acme at puberty, intellectual progress thenceforward being relati\-eh' slow. From the period of pulierty, at whatever age it may occur, the maturity of the reproductive apparatus begins, and in this respect the individual is as completed" equipped functionally as he will ever l.)e. Puberty means, therefore, ripeness of the procreative power, ability to beget or to couceive, the culmination of eliildhood, and immergence into physical maturity. The voice of the boy changes at that time, coarse hair begins to grow upon the skin and in particular surrounds the ex- ternal genitals, the sexual appetite is aroused. In girls, similar phenom- ena upon the skin are apparent, the breasts enlarge, the curves of the body formed by the development of the muscles and fat are accentuated, and the inqxjrtant function of menstruation is established. This fuiu^- tion is peculiar, not only on account of its regular recurrences, its sus- l)ension under certain Avell-recognized conditions, notably the condition of pregnancy, but also from the fact that it is tlie visible exi^ression and announcement to the individual that the period of puberty with all its possibilities has arrived. No wonder that among primitive people who- 430 -^ SYSTEM OF LEGAL 2IEDICIXE. "were iu tlie least observaut the appearance of menstrnatiou slioiild be the oecasiou for the performance of appropriate rites and ceremonies* There are numerons factors which detewnine the time and the man- ner of the establishment of puberty. "\Miile these factors are influential for both sexes thej' ai-e especially so for the female, inasmuch as the female is usually more sensitively organized than the male. They may be regarded as subjective and objective : among the former are race and family pecnharities, general physical condition, temperament, etc. ; among the latter are climate, occupation, altitude, personal habits, etc. (See the wi'iters ''Disorders of Menstruation," Trans. X. Y. State Medical Society, 1889, p. 154.) In general it may be said that puberty oceiu's one or two years earlier in girls than in boys, earlier in warm than in cold chmates, earlier at the sea-level than at high altitudes, earher among those who are healthy than among the sickly and dehcate, earher among sav- ages than among the ci^Tlized. In boys puberty is most fi'equently reached between the thirteenth and sixteenth years. In gii-ls the limits are farther apart : it may occui- as early as the eighth or as late as the twentieth year. The latter limit is not at all unusual in very cold cli- mates, while in the tropics menstruation at ten years of age is not j)re- cocious. Even in our own climate maturity may occur very early, the widter being familiar with a numl^er of instances in which pregnancy occurred between the tweKth and fourteenth years. A question which is often a very important one relates to the coin- cidence or want of coincidence of menstruation and ovidation. Some writers are of the opinion that o^Tilation may. begin almost at bii"th. However this may be, it is certain that conception does not usually occur until menstruation has been established. On the other hand, menstrua- tion often occurs with considerable regularity when the ovaiies are absent. The establishment of menstruation is often a slow process — a discharge of blood may take place from the genitals, with the attendant phenomena of the nervous system, an interval of several months may follow, then another discharge of blood lasting several days, then per- haps a less prolonged interval before another recuiTence, and finally, after a year or so, the recurrences may be at stated monthly periods : or the function may assume fuU-fledged peculiarities fi-om the stai-t. The discharge of bloody fluid continues from one to six or se^'en days. gTad- uaUy increasing in Ciuantity until the maximimi is reached, and then as gradually receding and disappearing. There may be no accompanying j)henomena which are worthy of note, or there may be pain iu the back, headache, and general discomfort : and these symptoms vary within very wide limits, so that the period of menstruation is justly looked upon as one of the most important in the functional life of a woman. It is one which often calls for the most careful attention on the part of the physi- cian. It may demand examination of the genital organs, and sui-gical treatment for the relief of f aidts which are fundamental to the menstraal disorder, which if unrelieved make life a burden during a not inconsid- erable portion of every month. Earely does a boy reqim-e the same * Among the American Indians at the Quapaw (Ind. Terr.). Eoimd Valley (Cal.), and Neali Bay (Wash.) reservations sueh celebrations are observed. The ceremonies are somewhat disgusting to the civilized mind. (See the wi-iter's investigations rela- tive to the functions of tlie reproductive apparatus in American Indian women. Trans. Amer. Gyn. Soc, vol. xvi., p. 272.) BIRTH, SEX, riiEGNAMJY, AM) DELIVERY. 431 careful and prolonged supervision as a girl while pul)erty is being estab- lished, liii certainly should be instructed during- or l)efore that period con- cerning- tlie control of his sexual appetite and the care of the sexual organs, neglected though this duty nsually is; but he suffers far less frequently than the girl from defects and disorders of his sexual organs, and far less frequently does his future welfare dei^end upon the wise counsel and treatment of his physician at this time. Gynecology, the- science which deals particularly with tiie diseases peculiar to women, has done very much to mitigate the ills and e^•ils of the i)eri()d of puberty, as well as of subsequent periods; and if it has sometimes showu excess of zeal in the treatment of such conditions, which call for tiie highest nuinifestations of tact, skill, modesty, and con- scientiousness, it still has a proud record in the relief of present discom- fort and the wisdom with which it has frequently anticipated trouble which was impending. The infiuenees of climate, altitude, and the gen- eral condition of the individual have been referred to as factors in deter- mining the early or late appearance of pulierty, and we have also seen that in some cases it was established without disturbance while in others it was attended by pertm-l^ations or storms, repeatedly recurring, until the system had adjusted itself, as it were, to the new conditions. In boys, if they have been the victims of nervous disease, such as ei:)ilepsy or chorea, the disease may disappear at puberty ; or, on the other hand, it may be exaggerated, especially if the subjects are masturbators. The same is true with regard to girls, and it is at this time, also, that the hys- terical temperament is wont to become apparent. It nuiy l)e added that this is also the Ijest time to bring it under control. Insanity develops at this period of life with far less frequency than at the period which ushers in old age with its degenerative tendencies and processes. Malignant disease, which is also frequently associated with the period of senility and decay, seldom makes its attacks at puberty. Certain serious consti- tutional diseases, such as pulmonary consumption, frequently become ex- aggerated at this time, but it is not clear that this is necessarily due to any influence x)eculiar to jmberty. On the whole it may be said that this period should be as conducive to robustness of physical condition as any l)eriod of life, for it is the time of youth and exuberant physical activity. Consequently there is seldom anything in the experience of puberty to impair the legal accountal)ility of the indi\ddual in so far as a stage of legal accountability has been reached at that epoch of moral and intel- lectual development. Menstruation or the menstrual flow is a discharge of blood and other material whicdi is derived from the uterus, ovaries, and Fallopian tubes. It recurs with considerable regularity each lunar month in females who have attained the age of pu])erty, if they are not pregnant and ai-e not suffering with any wasting disease. It continues, as we have already seen, under mn-nial conditions, from one to six or seven days. It is composed not only of l)lood but of glandidar secretions and degenerated t issue-material, and, unlike the blood under its ordinary conditions, does not coagulate or clot except when the eii'cumstances attending its dis- cliarge are unusual or pathological. A somewhat analogous discharge is observed among many of the lower animals, and in the apes and monkeys it has decided resemblances to the monthly flow of women. With the animals the flow coincides with the rut, or period of heat, that 432 ^ SYSTEM OF LEGAL MEDICINE. is, the period of active sexual desire, whicli is the natural expression of functional acti\T.t3^ of the reproductive apparatus. It is not improbable that the function of menstruation is an outgrowth or evolutionary pro- cess of the conditiou which has been referred to in animals. Its modi- fications and varying effects are apparent enough as woman advances in the scale of civilization and iutellectual development. One of the char- acteristic f eatiu'es of the menstrual function is the increase in the tension of the Ijlood-vessels, especially in those which suppty the genital organs. The tension being greater than the resistance of the superficial vessels in those organs, ruptui'e and hemorrhage result. "Wlien menstruation is performed under noiinal conditions it gives rise to no particular disturb- a^nce, with the exception of the annoyance from a moist and sometimes malodorous discharge, and even this annoyance may be entirely over- -come \)j the use of suitable means. Like all the other functions of the body, it is 23ainless when it is normally performed. The most reasonable theory in regard to its object, and the one which comports most with the analogous function in the lower animals, is that it serves as the expression of the fact that a membrane or decidua has been formed in the uterus for the reception of an ovum, such a membrane being an indisjDcn sable necessity should insemination of the ovum and conception occur. Should such a result not occm* the unfertilized oyuwl passes out of the uterus, and the decidua, mth the small vessels which it contains, breaks down and is washed away by the blood-current, the latter forming one of the phenomena of menstruation. Should this phenomenon fail to make its appearance at the customary time, it is often, but not always, the sign that conception has taken jDlace. The abnormalities of the menstrual function are many. In civilized life, especially in the cities and among those whose manner of li^dng is artificial and highly irregidar, there are more women who experience pain and annoyance with menstruation than there are of those who pass through it uncousciously and naturally. This might be regarded, from one point of view, as an argument that civilization had acted unfavorably upon the physical condiTiou of woman. The faidt, however, is not exactly that of civilization, but of its accom- paniments of wealth and poverty, vices and excesses, neglect to inculcate in the j'oung the importance of hygienic laws and precautions. Among savages and barbarians the abnormalities in question are of rare occur- rence. The following digi'essions from normal conditions are often observed : 1. Painful menstniation, or dysmenorrhea. 2. Profuse menstruation, or jDolymenorrhea. 3. Scanty menstruation, or oligomenon-hea. 4. Absence of menstruation, or amenorrhea. 5. Irregular or substitutional menstruation, or atopomenon'hea. The first of these abnormal conditions, always referred to by physi- cians as dysmenorrhea, is so common that many physicians are of the opinion that it is almost a necessary and unvarying accompaniment of the function. This we deny, both because of exjjerience in the observa- tion of many cases in which menstruation was absolutely unaccompanied with pain, and because it would hardly be fan* to assume that so impor- tant a function was an exception to all the other functions of the body in being normally painful. "With many women pain is a symptom of menstruation only din-ing the earlier vears of life, nerhaps until they BIBTR, SEX, niEGNANCY, AND DELIVERY. 433 liave home one or iiioi-e (^liildren ; hut with others it is a eiistomnry and oxpec-ted and ti'ying' syin])toin durin<>- tlu^ entire pei-iod of life in which menstruation occurs. It is most fre([uently located in some portion of the head and. in the lumljar region of the ha(;k. Very often it is also in 1lie tliiglis .and legs and the muscular system in general. It may be ])r('se)it during the entire menstrual pei-iod, oi- dui'ing the day or two ])r('ceding it, or it may not occur until the blood l)egins to flow, this form being less common than the others. Pain may also b(; present in the stomacli a.iid l)ow('ls, with or without nausea and vomiting, and in the uttn-iis itself in the form of cramps or contractions, compMi'uble to the pains of labor, and oft(!n due to the blood which has accMimulated in tlie organ, which it takes this method to expel. Young and unmarried women are the greatest sufferers from this disorder, but the married ones and those who have borne children are by no means exempt. The effect of these repeated iittacks uj)on the mental condition, especially in those Avho are predisposed to mental disturbance, is sometimes very pronounced, many of the iniuivtes of lunatic asylums being sufferers from the severer forms of dysmenorrhea. In determining the cause of insanity it is very important to ascertain the history of the patient with respect to her menstrual function. Profuse hemorrhage during the menstrual period is sufliciently com- mon, but less so than dysmenorrhea, the condition just described. Its ■cause is often apparent enough vv^hen there are tumors in the uterine structure or when the mucous membrane of the uterus is diseased from other (pauses, but frequently the cause is obscure. It is a common occur- rence in young girls who are anemic but witliout percepti))le disease in the woml) itself, the hemorrhage rediTcing their strength and sometimes bringing them to the verge of collapse. It is common in prostitutes and others who have abused the sexual act, in those who have suffered abor- tion which has been imperfectly or improperly treated, and occurs almost invariably in those who suffer with malignant disease of the womb or its appendages. The hemorrhage may appear in gushes, in clots, or in a continuous leakage lasting many days. In some cases a woman has barely time to rally from one attack before she is seized with another. Unless the root of the matter can be quickly reached such women be- •come hopeless invalids, djdng from exhaustion or becoming an easy prey to disease of some other character. Scanty menstruation may be an indication of a depraved general condition or of some disturbance located in the genital organs. The menstrual period may last only a few hours or it may extend over several days, the quantity of blood lost each day being insufficient to relieve the tension in the T)lood-vessels and give the woman a sense of relief. It may be due to a sudden checking of the menstrual flow caused by low temperature, a high wind, a cold bath, or a profound mental emotion. It is often accompanied with severe pain (dysmenorrliea) ; the blood itself may be pale and watery, with an unusually small proportion of the constituents (especially the red corpuscles) of healthy blood. The con- dition is usually amenable to relief, either Iw measures directed to the genei-al condition or by treatment of the genital organs themselves ; but it is far less frequently an expression of organic disease than is profuse menstruation, and far less calculated to cause alarm on the patient's behalf. 434 ^ SYSTEM OF LEGAL MEDICIXE. Absence of menstruation, or amenorrliea, is relatively an infrequent condition, those cases being excluded, of course, in wliich it is an acconi- paninient of the pregnant state. The cause is sometimes quite beyond the existing state of our knowledge, but at others a rational explanation is entirety possible. It sometimes occurs in women who are suffering with severe wasting disease, such as pulmonary tuberculosis, chronic Bright's disease, or diabetes. It may occur in connection with an ocean voyage or residence by the sea. Many of the young immigrants to this country suffer in this way for months, if they remain at the sea-coast ; but it usiially disappears, leaving no bad effects, after they have become accustomed to the chmate. It is sometimes observed in women who are well developed, but who in early life have suffered mth chorea, epilepsy^ or some other disease of the nervous system. Very fat women occa- sionally suffer in this way. It is suggestive of pregnancy, and women who are thus affected frequently consult a physician in great alarm, fearing pregnane}^, especially if they are single and have good reason for fearing that such a condition might exist. It is a common superstition that it may cause or lead to consumpiion. This it never does in and of itself. It is often a conservative process on the part of nature when the woman is too weak to bear without detriment the loss of even a small quantity of blood ; and this is a most important point for the medical jurist. The superstition alluded to is probabh^ attributable to the fact already men- tioned, that it may be an incident in the course of the wasting diseases. In such cases it is both post Jwc and propter lioc. At the present time, when the removal of the ovaries is of such frequent occurrence, it is an almost inevitable result, and is a matter of daily observation. It is reme- diable in many waj^s — by removal of the residence from a moist to a dry climate, by improvement of the general condition, and by removal of ex- isting causes in the genital organs. It is irremediable if due to the removal of the ovaries, or the uterus and ovaries, or if the patient is suf- fering with the incurable diseases such as were mentioned as its causes. Irregular or displaced or substitutional menstruation is the variety which has often been called \acarious menstruation, a term which is mis- leading and objectionable. The somewhat clumsy term atopomenorrhea is suggested as a substitute which is correct etymologically and explicit. It is a substitute for menstruation of the ordinary t^-pe or it may be a sort of addendum to it. One variety of which the writer has seen several instances consists in spots or patches of a dark-red color upon the skin, known by dermatologists as purpura. These spots are caused by exuda- tions of blood from the vessels beneath the surface of the skin. Xitvi or birth-marks are usually swollen and darker in color than usual duiing menstiniation. The blood or blood-serum may even exude through the skin like a bloody sweat, and cases of this character have sometimes ])een used to impose upon the minds of the superstitious and the credulous. In women who have ulcers or open sores the disr-harge therefrom is more aljundant during the menstrual period than at other times, on account of the rise of the blood-pressure which then obtains. Other varieties of atopouienorrhea are bloody diarrhea, bleeding from the gums, the nose, the anterior chamber of the eye, vomiting of blood from the stomach. Malingerers have been known to swallow blood, or red fluid resembling blood, and then vomit it as an exhibition of abnormal menstruation, especially if the object be to excite attention or notoriety. BIRTH, SEX, rnEGXAXCY, AXIJ DELIVERY. 435. In all these cases it becomes the duty of the ph3-si('iaii to ascertain ■wht'ther the tiuid ejected is a natural product or Avhetlier it is the result of fraud on the part of tlie individual, the opportunities for deceit and imposition heing' abundant. Concerning- the relation of menstruation to gestation, the menstrual flow and its attendant phenomena are ordinarily absent during gest;i- tion, and the explanation appears in the theory of menstruation which lias been given. But this is not always the case : some women menstru- ate regularly while pregnant the same as in the nnimpregnated state. In the dangerous eoiulition known as placenta pranda, in whi(!h thi-; pla- centa is inii)lanted directty over the internal opening of the womb, a dis- charge of l)lood occurs every month and ma}^ result in aljortion or eveu in fatal consequences. If mahgnant disease coexists with pregnancy, hem- ori'liage may take place either at the custonuiry time of menstruation or at irregular intervals. In aU cases of pregnancy in which hemoii-hage takes place, whether at regular or ii-regular intervals, it is very desii'able to ascertain its cause, for serious consequences may thereby be averted. If the meiisti'ual flow occurs in any other than the normal manner — if it is too aliundant or too scanty, if it continues too long, at too frequent or at too infrequent intervals — its cause should be ascertained as promptly as possible. It has been shown that such irregularity may be associated Nvith disease of the uterus, the Fallopian tubes, or the ovaries, and the bearing of -Any such possible conditions must be carefuUy determined. Gonorrhea involving any of the genital organs may produce a bloody discharge ; also syphilis, abscess of the pelvis, or pelvic congestion from any other cause. Certain diseases of the bladder and urethra are also accompanied with hemorrhage, and such a discharge must not be mis- taken for the menstrual flow. Bloody discharges fi'om the rectum and anus must also be carefully referred to their proper origin and not be hastily regarded as an evidence of abnormal menstruation. It will there- fore be apparent that all discharges of blood from the female genital organs ar« of very decided significance, and only by careful attention can their true natiu-e be determined. The menopause, or change of life as it is commonly called, marks one- of the important eras in the life of a woman. Puberty announces the initiation of the cliild-l)earing period, the menopause its termination. By this term is meant primarily the cessation of the menstrual funetiou. In temperate climates it occurs, in the great majority of instances, be- tween the fortieth and fiftieth years.* In very warm and in ^Tiy cold climates it often occm-s prior to the fortieth year. Those who reach puberty early frequently reach the menopause late in life. Those who bear many children in rapid succession, also those who are very fat, usually cease menstruating early. The same is true of those who suifer with the wasting and exhausting diseases : as was remarked in a pre\ioiis part of this article, the limit of the reproductive force has been reached, and is evidently dependent upon the general condition of nutrition of the body. Those whose ovaries have been removed experience the meno- pause as the direct consequence of such an operation. * This rule is very far from universal in its application. The Avriter has known many instances in which menstrnation Ims occurred as late as the fifty-fourth year without interruption. Very late occurrence of the menopause is a noteworthy char- acteristic in many families. 436 ^ SYSTEM OF LEGAL MEDICINE. The menstrual function may terminate abruptly or gradually, tlie interval between the periods gradually lengthening iintil they cease alto- gether. If a bloody discharge from the genitals recurs after the meno- pause has taken place it may be regarded as an unfailing evidence of disease, and it is usually an e\ddence of serious disease. No one of exiDcrience, nowadaj^s, would think of attributing to menstruation a hemorrhage or series of hemorrhages occurring five or ten years or even longer after the disappearance of the menstrual function, though such diagnoses were common enough in the practice of a generation ago and earlier. The menopause marks not onlj^ the cessation of menstruation and the child-bearing function, but the advent of diminished resisting power of the tissues and organs to disease processes. Repair now takes place less readily than in the previous years of life, and the individual is more susceptible to disease. Cancer and other malignant and degenerative processes are prone to develop, also insanity' and other diseases of the nervons system. Women who are passing through the menopause are often troubled with sudden flashes of heat upon the surface of the body, especially about the face and head, w^hich appear without warning and vanish as mysteriously ; they may snif er with unaccountable attacks of hysteria, with disorder of the stomach, liver, and bowels, or with great irritation of the kidnej^s and bladder. In fact, if the menopause is a stormy one, as it very often is, they are to be judged by a different standard of phj^s- ical condition and behavior from that which is applicable to younger women or to those who are fortunate in getting through it without I)articular perturbation. In consideration of the many possibilities of discomfort of this period a grave responsibility is laid upon the gyneco- logical surgeon who may be caRed upon to perform an operation which win precipitate it. The frequency with which this operation is done sometimes gives rise to the suspicion that these possibilities have not been weighed with sufficient care. The subject is certain to require more profound and extensive consideration at the hands of the jurist than it has heretofore received.* In women who are the victims of fibroid tumor of the nterus the menopanse usually comes later than with those who are free from such disease. Schorler (see GTnsserow, NeuMMungen des Uterus, p. 28) found the average age of the menopause in women without tumors to be 47.13 years. Of those who had tumors the average of 29 in private practice was 49.14 years, and of 23 in hospital practice 48 years. In Gusserow's investigations menstruation persisted at 50 years in 5.4 percent, of aU cases of filjroid tumor of the nterus in private practice, and in 7.7 per- cent, in hospital practice. The teaching that fibroid tumors of the nterus are quiescent and harmless after the menopause is frequently erroneous. The Aviiter recently removed the uterus with a large fibroid tumor which -svas firmly fixed in the pelvis and actively growing from a woman who had passed the menopause two years previously. The tumor was abun- dantly nourished l;)y the adhesions in which it was ensheathed. * In this connection see a timely article by Goodell, " The Effect of Castration on "Women, and other Problems in Gjaiecology," Annals of Gynecology, January, 1894, p. 198. BIETH, SEX, rUEuyAXCY, JSU DELlVEliY. 437 III. PKEGNAXCY. Marri(i(/e and Coiiccpfioii — Sfi'riJifij — Evidences of Pregnancy in its Early Sfaycs, also in its Later stages — Conditions which simulate Pregnancy — ISitperfetation — Complicated Pregnancies — Age-liniifa irithin n:hich Pregnancy is Possible — Can Pregnancy Ej-ist and the Mother he Igno- rant of the Fact? — Viability — Duration of Gestation under Ordinary and Extraordinary Conditions — I)eterniinatio)i of the Period tcJiich Pregiiancy has Beached in a Given Case — Legal Questions Relating to the Foregoing. Marriage implies the possibility of sexual intercourse ; sexual inter- course during- the child-bearing jjeriod implies the possibility of concep- tion : judging from analogy in many of the lower animals, that is its phj^siological object and not solety the gratification of the sexual appe- tite. If conception does not take place after sexual intercourse it is because the conditions as to ovulation are unfavorable, or because of physical disability on the part of the man or the woman, or because of mechanical interference in some way or other. This statement is com- prehensive enough to answer and explain many facts and questions. It explains the failure of countless women to become pregnant though they and their husbands long for children with earnest longing. It explains the failure of other women to become pregnant who would not submit to pregnancy and labor if there were any possible way of a^-oiding it. It also suggests the explanation of pregnancy when it occurs against the will of the pregnant, and when they were under the impression that they had used all the means which were necessary to prevent conception. It is not affirmed by the writer that absolute non-interference ])rior to con- ception is the proper and only line of conduct to be followed. In this respect he is well aware that all of his medical brethren will not agree with him. It seems to him that there are cases in which interference to prevent conception is desirable and just, and not injiuious to the ph^-sical condition of either the husband or the wife. Indiscriminate intercoui'se between those who are not married to each other is excluded as at all times immoral, unnecessary, and improper. That men and women are •often very badlj^ mated is abundantly sho"RTi by the hideous mental, physical, and moral monstrosities and deformities which result from such unions. It ^\'ould be well for the world if the reproductive power of many individuals Avere terminated. A stock-raiser who should breed his animals with no more care and thoughtfulness than is exercised by the average of human beings woidd soon be compelled to go out of the business. G-reater "wisdom in the pau-ing of men and women, "wisdom al pregnancy in the writer's knowledge, in which such abnormalities have been present, have eoutirmed his views in regard to the correctness of these statements. The ovum and spermatozoon having united, conception becomes a fact, the ovum becoming imbedded or implanted in the uteriue mucous mem- brane, and developing in accordance Avith physiological laws which have been carefully investigated and clearly determined, and which are embod- ied in the beautiful science of emliryology. If pregnancy proceeds normally the first evidence or iutinuition of its presence to the woman consists in the absence of the menstrual flow when the time for its apjDearance has arrived. At this early stage of gestation the ovum may be readily dis- lodged, and mau}^ abortions are produced by the drastic remedies which, are taken by women who are alarmed because their "sickness" does not appear. If the ovum is not disturbed and the time for the menstrual flow recurs again with experience similar to that of the preceding mouth the hope or suspicion of pregnancy which was entertained by the woman wiU, in most cases, have developed into a certainty. If the woman is pregnant for the first time she will usually be a sufferer with nausea and vomiting, especially in the early hom-s of the day (morning sickness) ; her breasts will begin to enlarge, and perhaps be pixinful. In a certain num- ber of cases there will be milk in the breasts, but this is by no means a customary occurrence. The changing contour of the abdomen will com- l)el the woman to loosen her clothes about her waist. Cousti});ition will frequently be a troublesome symptom, also an abundant leucorrheal dis- charge from the vagina. The appetite may be increased, and the strug- gle between increase of the appetite and inability to retain the food which is taken is often very distressing. Such ai'e the principal sub- jective symptoms during the first two months of pregnancy. If a phy- sician is called on account of the non-appearance of the menstrual flow at the customary time he may be assisted in his diagnosis by the state- ments of the patient, or they may be intended to mislead and deceive him; he should therefore be on his guard against deception and de])end upon objective rather than su])jective symptoms. He should refrain from introducing instruments into the uterus, as he might inadvertently punctui-e the ovum, produce an al)ortion, and thus accomplish the very end which his patient desired, though she may not have expressed such a desire. If the pregnancy has not advanced beyond the fourth or fifth week a positive diagnosis of the condition may be very difficult or even impossil)le. An examination with the finger will usually i-eveal a soft- ness of the vaginal portion of the neck of the uterus, which is suggestive of pregnancy; and the bimanual examination will show that the uterus is larger and somewhat more globidar than in the uuini]n'egnated state: but there are no unfailiuG: siu'us which will indicate with absolute accu- 442 ^ SYSTEM OF LEGAL MEDLCIXE. raer tliat pregnaucT exists ; tlie s^-mi^toms meutioned may all be due to other causes, and Ijoth physician and patient may be compelled to await fmther developments before arriving at a conclusion* A sign, called after its discoverer Hegar's sign, and consisting in a bogginess and resiliency of the lower segment of the body of the uterus, is discernible from the fifth to the seventh week, but it is not constant and is not universally recognized as a sign of value. The sign upon ■wliich the wi-iter places gi'eatest dei)endence between the fifth and tenth weeks is the discoloration of the miicous membrane of the vulva and vestibule. This varies fi'om a pale purple to a pale violet, in place of the light-piok hue of the unimpregnated state. It implies obstruction .of the venous circulation of the tissue involved, and, while it may be an indication of obstruction from some cause apart fi'om pregnancy, it is of gi'eat value in detennuiing a diagnosis when taken in conjunction with the other early signs of the pregnant state. It is the first sign which arrests the attention of the practiced eye in making an inspection of the genitals. It has been observed by the writer in hundi'eds of in- , stances and has rarely proved misleading. From the second month of pregnancy onward the signs ma}' still be .considered with advantage from a subjective and an objective stand- point, the foiiner being first considered. The menses continue to be wanting ; the breasts continue to enlarge, and give rise to more or less pain and soreness • nausea and vomiting persist until the fifth or sixth month and gradually disappear as the womb rises from the pelvis into the more cax3aeious aljdominal ca^it}', though in some cases tliej' con- tinue until the end of pregnancy. The patient has uncontrollable drow- siness and sleeps much of the time, also backache, vaginal leucorrhea, frequent uiclination to ui'inate, and other annoyances ; or, on the other hand, the latter poi-tion of j^regnancy may lie free from discomfort, or even attended liy a gi-eater degree of comfort than is customary in the imimpregnated state. One of the most important of the subjective sjTnptoms of pregnancy is quicl'eriing, which is a peculiar sensation, some- times compared to the fluttering of a bu-d, caused by the movements of the fetus within the womb, and the first intimation to the mother that ;She is cariying in her body a li^-ing, moving being. Of the objective signs the discoloration of the Aiilvar mucous mem- 'brane becomes more and more marked as gestation progi-esses, until, during the last month, the color may be ahnost black. In some eases the veins of this region are much enlarged and resemlile bimches or * Diekinson (^Xeu- York Journal of Gynecology and Obstetrics, November, 1893, p. 985) offers the following scheme concerning" the early signs of pregnancy, -which is ihe most recent contribution to the subject : Six sisms of early pregnancy obtained by the bimanual examination : 1. Bellving or bulging out of the bodv of the uterus. 1 2. Elasticity or bogginess of the body of the uterus. ^^^^^^^ ^^^^, ^^ .^ ^^^^^^ S. Compressibility of the lower uterine segment. 4. The transverse fold. J 5. The longitudinal fold or furrow. J ^^^^^^^ ^^^ ^^ ^.^^ ^^^^^^ 6. The denser spot. S ^ Dickinson thinks that in favorable cases the presence or absence of pregnancy may be determined between the second and sixth week after coitus, or between the third jind eighth after the beginning of the last menstruation. lilh'Tir, SJ:.\, I'HECSASCV, AXD DIlLll'ERY. 44;j clusters of worms. The softness of the v;i<>ina and vaginal portion of the neck of the womb also ])ee()nies more pronouneed; the eervical eaual ])('c,omes patulous, readily admittinj^' the end of the index-fin, u'cr as the time for labor ai)pr()aehes. Tlie enlargement and aseent of the uterus ])rogress, pari pas.sii, with the development of gestation. There is little (liffereuee of deseriptioii among- the best obstetrie writers concerning the relations of the uterus to its surroundings dur-ing the different months ot {)regnan('Y. We shall follow the description of Winckel {Text-hook of Ob.sf ('fries, 1S90, p. 79 et seq.) : At the end of the second month the fundus of the uterus can be felt by the examining hand behind the sijiuplnjais inihis. At the third month the uterus is as large as a man's fist, and the ab- •donu^n begins to be prominent. At the fourth month the fundus of the uterus has risen out of the pelvis. At the fifth month the fundus is midway between the symphysis and the navel. StriaQ l)egin to apjiear upon the surface of the abdomen, and the Tinea aiha assumes anu)re })igmented appearance. During this month the sound of the fetal heart may be detected in manj' cases. At the sixth montli the fundus rises to a point about two iingers' breadth below the navel, and its lower half l)ecomes flatter. At the seventh month the fundus is two fingers' l)readth above the navel, and- during this montli the lower pole of the fetus may usually be felt through the vagina, though the fetus is still quite movable in the fluid in which it floats. At the eighth month the fundus is midway between the navel and the epigastrium, the lateral expansion of the uterus is consideral)le, and the movements of the child are very vigorous and can readily be felt when the hand is placed upon the abdomen. During the ninth nnnitli the fundus nearly reaches the epigastrium, continues to expand laterally, and in the closing weeks of pregnancy the presenting portion of the fetus descends into the pelvis, preparatory to its exit from the birth canal. In addition to the gradual enlargement, hardness, and soreness of the breasts during pregnancy, an important point to be observed in making a diagnosis is the enlargement of the papilla3 or sebaceous glands sur- rounding the nipple, also the greater pronunence of the idpple, the in- crease in the deposit of pigment in the colored areola around the nipple, and the development of a secondary areola around the first, which is lighter in color and narrower than the first, and does not appear until the later months of pregnancy. Among tlie objective signs of preg- nancy which were formerly more frequently alluded to than they are at the present time may be mentioned liesfein and halJoffenienf. The former was first brought to the attention of the profession by Nauche, who asserted that its presence in the urine was a cei'tain sign of pregnancy ; it (H)nsists simply of tri})le phosphates and low forms of life — but it is also found in the urine of nudes (Winckel, Joe. cif.). It has frequeutl}^ been referred to in works on medical jurispi'udence as a diagnostic sign. Ikdlottemenf, which consists in pressing snuirtly upon the fetus with a finger in the vagina, the ball of the finger being applied to the anterior vaginal wall, the pressin-e causing the fetus to rise in the fluid in wliicli 444 ^ SYSTEM OF LEGAL MEDICINE. it is immersed and then rebound against tlie finger, is a good enough sign, but not always practicable nor easily accomplished. Besides, it is- unnecessary because there are so many other means of determining pregnancy which are easier of application and jast as reliable. The condition of the kidneys must not be overlooked in determining preg- nane}', especially if there is any suspicion that disease of these organs- existed prior to ]3regnancy. Frequent examinations of the urine should be made, especially with reference to the presence of albumin. A trace of albumin during the earlier months need not cause alarm, but if, after the sixth month, when there is more or less pressure from the uterus- upon the kidneys, there is albumin to any considerable extent in the urine, the condition becomes one of grave importance and calls for the most careful watchfulness and wisdom on the part of the physician. Eclampsia or convulsions is sometimes associated with renal disease during the latter portion of pregnancy, and constitutes one of the most dangerous complications of the pregnant, partiuient, or puerjDeral state. There are no peculiar conditions of the heart, lungs, intestines, or other viscera during pregnancy which call for particular attention in a book of this character. The systematic treatises on obstetrics may be consulted in regard to all such unusual incidents. It is a well-known fact that deceit is often practiced by those who desire to be pregnant, as well as by those who desire to be relieved of pregnancy, the physician being- often imposed upon by both. Erroneous diagnoses are made by physi- cians through ignorance, want of discrimination, and sometimes on ac- count of difficulties which render error quite pardonable. Mistakes of this kind are far less frequent than formerly, for the general diffusion of gynecological knowledge has informed the profession at large con- cerning the anatomy of the pelvis to a far greater extent than ever before. Cases which simulate pregnancy may be divided into two groups, in the first of which enlargement of the abdomen will be the chief symp- tom, while in the second this symptom may or may not be present, other noteworthy symptoms being prominent. According to this classification individuals of tbe first-mentioned variety and their friends may be de- ceived by the situation, but the phj'^sician usua,lly will not be. In the- second case the j)liysician also may be the victim of deception. The most conspicuous members of the first group include those women with whom the great object and desire of life is to become preg- nant. This group also includes cases which are interesting and impor- tant, and in which the entail of an estate depends upon the birth of an heir. The intense desire of these women to have children very often leads them to imagine that they are pregnant whether there is any gi'ound for it or not. A famous illustration of this group was Queen Mary of England, wife of Philip II. of Spain, who was continually report- ing herself pregnant, and even appointing the time for her accouchement. The eidargement of the abdomen in these cases is usually due to ferment- ative changes in the intestines, with resulting accumulation of gas and such gastric aiul intestinal disturbance as is not an uncommon accom- paniment of pregnancy. The distention of the abdomen from this cause may continue a long time, and a woman who is thus affected may readily deceive herself with the thought that she is pregnant, especially if she; BIRTH, SEX, niEGXANCY, AND DELIVERY. 445 liappeiis to l)c very anxious to Ijoeoinc so ; aud the deception is fostered by sympathizing- friends who have had a soniewliat siniihir experienee in connection with their own pregnancies. A condition of this cliai-acter slioukl never mislead a physician, because he can determine by examina- tion, with the aid of an anesthetic if necessary, whetiier tlie distention is gaseous or due to an enhirgement of the uterus, or to the two causes combined. Collections of fluid in the abdomen nuiy simulate pregnancy. Such collections occur in connection with maligiumt disease of the al3- dominal \dscera or with tuberculosis of the peritoneum. This condition sometimes occurs in young unnuirried women, and the unjust suspicion which is aroused is peculiarly cruel l)y adding to the hardships of a dis- ease which, in malignant cases at least, is hopelessly incuralile. Enlarge- ment of the abdomen due to the presence of an unusuall}^ aljundant deposit of fat in its wall, or to solid or fluid tumors in its cavity, may simulate pregnancy. The fii'st of these statements need not seem in- credible, since a layer of abdominal fat three or four inches in depth is not uncommon. The tumors referred to have mauy tiines been mistaken by the uninitiated as evidence of pregnancy, to the great detriment and unhappiness of those ^\\\o suffer with them.* Before the time when ovarian tumors were well understood, those who had them were often accused of pregnancy. The injustice of such accusations was in some notable instances demonstrated by the removal of the tumors after death. Happily such growths are now removed Avith such facility and comparative safety that an innocent w^oman need no longer suffer such aspersions until her veracity can be attested by a post-mortem examination. But in the second group of cases mentioned the conditions which simulate pregnancy may be of such a character as to deceive even the ex- pert diagnostician : first, when the uterus alone is affected ; second, when the diffi(;ulties involve other organs of the genital aj)paratus. The uterus may enlarge slowly aud symmetrically on account of the presence of a fibroid, a fibrocystic, or a pnrely malignant growth, the enlargement being strongly suggestive of the early months of pregnancy. A single examination may leave the physician in doubt as to the existing state of affairs, and it may be necessary to repeat the examination several times at short intervals. A spm-ious pregnancy in the form of a mole or a hydatid tumor of the uterus may also prove misleading. Cessation of the menses from any of the causes mentioned in the remarks concerning menstruation (q.v.) may also mislead both the patient and the physician. The presence of milk in the breasts is always suggestive of the pregnant state, but it may be an isolated symptom. t Softness and swelling of the vagina and cervix and external genitals, and discoloration of the vulvar * It imist ho remoinbeved that these tumors may coexist witli pregnancy, intro- ducing an element of gva\'ity which may be very serious. t A particuUirly notewortliy case was seen by the writer in 1891. The patient was an Irishwoman, tliirty-one years of age, who had been pregnant but once, having borne a cliihl Avlien sixteen years of age. For several years prior to ISOl there was milk in her breasts, and for the two years immediately preceding it was constantly present, as much as a tablesiioonful being frequently removed at once. She had suf- fered six years with disease of the pelvic organs, but the exact relation of this to the active condition of her mammarv glands could not be ascertained. 446 ^ SYSTEM OF LEGAL MEDICINE. mucous membrane caused hj interference with tlie cii'culation on account of neoplasms in the ^^elvis, may make it difficult or impossible to affirm or deny the existence of pregnancy. Multiple pregnancy, in ^\'hich two or even tkree fetuses are de\'eloped simultaneously, is sufficiently well known as a physiological fact. King {Manual of Obstetrics, 1892, p. 341) states that twin pregnancies occur once in seventy-five cases, triplets once in five thousand, and that quad- ruplets and quintuplets are extremelj^ rare. Winckel behe^'es that fi^ e is the largest number of fetuses that a woman can sustain in her uterus at once, and that the statements, especially in ancient literature, con- cerning women who have had more than five infants at a bii'th are fabu- lous. Well-authenticated reports of quadruplet and quintuplet bii-ths are to be found in recent literatiu"e. (Winckel, 07;. cit., p. 114.) These multiple pregnancies may result from one ovum which has undergone subdivision, or each fetus may be the product of a separate ovum. Superfetation, or the condition in which fecundation of an ovum has taken place after development has begun in an ovum in the same uterus which has been fecundated at an earlier period, is considered a possibil- ity, but one which has not yet been proved. In the condition which is /■ '^J Fig. 66.— Author's case of double uterus (uterus bicornis unicoUis). ' known as double uterus (see figures and history*), in which there are two distinct uterine bodies, union of the two having failed to take place during fetal life in accordance with the usual course of development, there may be simultaneous or nearly simultaneous impregnation in each * Antlwr's Case of Double Uterus. — The patient was an Irish"woman, twenty-five years of age, first seen August 15, 1889. She had borne five children Avithin a period of five years, all the labors having been tedious, and the last three of them breech presentations. She had had no miscarriages, and there was nothing noteworthy about her menstrual history. The vaginal portion of the cervix uteri was very large, indu- rated, and fissured, the uterus retrofiexed and adherent. There were large external hemorrhoids and fissiire of the aniis. These latter difficulties were fii-st operated upon ; then Emmet's operation was performed upon the cerA-ix, the opei-ation not resulting satisfactorily. Subsequently the cervix was ampiitated and the ruptured perineum closed, the result being good. A month later the abdomen was opened to relieve the adherent uterus, and the condition found which is represented in the picture. The round ligament of each uterus was shortened, the organ being thereby brought into its normal relations. The patient recovered without mishap. This anomalous condi- tion is termed by Kussmaul uterus bicornis unicoUis. BIETn, SEX, PREGNANCY, AND DELIVERY. 447 cavity, or it may take place in one after quite an interval from its occur- rence in the other. In such cases one of the children niij^ht be born (lays or wet^ks before the other. It is even possiljle in a normal uterus in wliich there is a twin pregnancy that development may not proceed absolutely puri pussu^ and that one fetus may mature and be delivered somewhat sooner than the other, the supposition being* in such cases, of course, that the two fetuses are in two separate ova. The late Dr. For- dyce Barker repoi-ts a case in which a woman gave birth to a child from one horn of a double uterus July 10, 1855, and to another from the other horn September 22, 1855. Cases are recorded in wliich black women have borne twins, one of them Ijeing black and the other white. This is probably due, as Lusk has suggested, to the detachment of two ova at the same menstrual period, and to coitus with a black man and also with a white man while the ova were still in the uterus. The same writer thinks that impregnation at two periods of time remote from each other, in the same uterus, must be regarded as inadmissible until ph3'siologists shall succeed in demonstrating in a single instance, by the presence of corpora liitea in different stages of development, that ovulation ever occurs during pregnancy.* In addition to the peculiarities which are involved in that form of pregnancy which has just been considered the pregnant state is suscejjti- ble of others of a most interesting though usually \Qvy grave character. Allusion is made to the so-called ectopic pregnancy, in which the o\T.im is implanted outside the cavity of the uterus and usually in some portion of the Fallopian tube (see illustration of the author's case of tubal preg- nancy, with accompanying history t). The principal facts in regard to this most undesirable method of fetal development have ah-eady been given in an earlier part of this article, and ueed not be repeated. A number of cases have been reported in which K^iug children have been I'emoved through an incision in the abdomen after having developed in this abnormal manner ; but they have been defective and short-lived in alinost all cases. What is stiU more strange, there are cases on record in which two fetuses have been found in the same tube, in different stages of development ; also cases with one fetus in each tube, and others with one fetus in a tube and another where it belonged, in the cavity of the uterus. Such facts are quite in the i-ealm of the marvelous, and impi-ess us with wonder at the eccentricities of which natvu'e is capable. The advent of puberty in the female is, as w'e have seen, usually re- garded as the announcement that conception is now a possibility. The age at which this occurs, as well as the age when the child-bearing func- * Obsteti'ic'ians of tlie liigliest authority admit the existence of superfetation in animals. Schroeder narrates a numher of such cases (Lchrbuch dcr GchurtsJiiilfc, ISSO, ]). 7(5) ; hut tlie same high authority, with Kleinwachter, Lelshman, Seanzoni. Wagner, liamsbotham, and Churchill, all concur in denying the existence of any reliable evi- dence, thus far, that superfetation ever occurs in women. t A recent case of the writer's, a drawing of wliich is given herewith, illustrates in a general way the condition of tubal pre,gnancy. This case was that of a negro woman thirty-three years of age, who had given birth to one child twelve years ago (1882). She had been complaining for some weeks jirior to operation, which was performed February 12, 1894, but pregnancy was not suspected. The tumor A repre- sented the results of pregnancy. It was as large as a hen's egg, and was intiniately associated with the tumor B, both tumors containing much blood and blood-clot. No 448 ^ SYSTEM OF LEGAL MEDICINE. tiou ceases, is, as we have also seen, variable, depending upon climate, race and family pecnliarities, and other well-known conditions. In tem- perate climates pregnancy rarely occurs earlier than the sixteenth or later than the forty-fifth year. In tropical climates women mature early o \ / V \b / / \ / Fig. 67.— Author's case of tubal pregnancy. The structures are seen in front or face view. V. Vagina; A^ o, left Fallopian tube, with tumor of pregnancy at A ; B, tumor of left ovary; F, normal right Fallopian tube ; O, normal right ovary. and the child-bearing function ceases early. Among the savages of New Mexico and Arizona (Mojaves, Apaches) complete womanly development is often seen as eavlj as the twelfth year. Among the Arabs of the desert the child-bearing period is said to end frequently as early as the twentieth year or soon thereafter. In cold climates puberty is delayed. Among the Esquimaux, as well as among the northern Swedes and Norwegians, it is often delayed until the eighteenth or twentieth year, the child-bearing function ceasing early from the same cause which delays puberty. Winckel is authority for the statement that in Germany the power of reproduction is estab- lished from the thirteenth to the fifteenth year. In India, with its warm climate and its pernicious system of child-marriages, early menstruation and conception are common, the latter sometimes occurring as early as the tenth year. Even in New York City, Barker has seen conception at the tenth year, and I. E. Taylor at the twelfth. The writer has seen it a number of times at the fourteenth year. At the other extreme, fetus was found in tumor A, but placental structure was shown by microscopical ex- amination made by three expert microscopists. The fetus probably died at a very early period and was quickly absorbed, the other structin-es retaining their vitality, and hemorrhasce had probably taken place on several occasions. Both ovaries and tubes were removed, the woman making an uneventful recovery. BIRTH, SEX, rilEGXAXCY, AXD DELIVERY. ' 449 Barker has seen a first preg-nancy as late as the fifty-second year, fol- Icjwed by a second and a third in the same person at the fifty-third and fifty-fifth years. He thinks this the hitest period of Avhich there is any authentic record of such an occurrence, with the exception of that of 8arah whicli is mentioned in the Book of Genesis* {TrS<>ci<'fij, 1S88, p. 301.) Legrand dn >S;nil]e (Mf'd&rine Jjfgnle, second edition) states, without referring to j)articular cases, that pregnancy may occur as hite as the seventieth year. Tlie question as to the possible existence of pregnancy without the knowledge or consciousness of the woman may be regarded from differ- ent standi)oints. We must consider not onl}^ the facts relating to the woman's physical condition, l)ut also the very important question of lier truthfulness. It is undenial)le that many women, especially- the young and unmarried, unblushingiy refuse to admit the possibilit}' of preg- nancy from its beginning to its termination, and it may be impossible to decide whether this is due to their untruthfulness or to their unconscious- ness of their condition. The deception or attempt to deceive must ulti- mately be exposed. In other cases, in which conception has taken place without the introduction of the penis into the vagina, in Avliich the hymen is practically intact, it is easy to understand the unwillingness on the part of the woman to believe that she can be pregnant. In cases in which coitus has taken place during sleep or intoxication or the hypnotic state, self-deception is also possible. There is also the class of cases associated with uterine or ovarian tumors, in which pregnancy has super- vened after the existence of the tumor was recognized. The writer has seen such a case in which pregnancy was unsuspected until labor actually began. Again, there is the entire class of extra-uterine pregnancies, in which the condition may not be suspected until the abdomen is opened by the surgeon for the purpose of removing a tumor the character of which he might be quite unable to determine in advance or until the situation is determined by autopsy. In a case which has been reported by the writer, a woman was luider the constant supervision of an acute and unusually inteUigent physician for weeks before her death. The latter event took place suddenly, after symptoms of great abdominal dis- turbance accompanied with agonizing pain. An a-utops}' was nuide, and when the abdomen was opened an infant, nearly full- grown, was found lying free in the abdominal cavity, where it had developed entirely out- side the uterus. Normal pregnancy has many times been mistaken even by the expert gynecologist for a tumor which required removal, the true situation becoming known only when the abdomen Avas opened. t From * The writer has been informed of a case which was known to one of his associates (Dr. G. W. Smallwood), in which delivery of a living child took place when the mother was sixty years of age, fourteen years after the menopause was supposed to have oc- ciirred. Such cases demonstrate the persistency of ovulation beyond the limit which has usually l)een fixed for that event. t Three such cases have occurred in the writer's practice in recent years. lu one, the wife of a physician, long under the writer's observation, presented all the char- acteristic sjanptoms of tubal pregnancy. The ■SATiter's diagnosis was conctirred in by a eolleagtie of great experience. The abdomen was opened and the uterus foimd dis- placed, but with the fetus within it and not outside of it. An abortion followed on tlie third day, and deatli from peritonitis several days later. In the second case there was disease of the ovaries, but tlie pregnancy was not recognized until tlie abdomen ^as opened. The patient recovered without abortion. In the third ease, a S\-i-ian 450 -=i STSTi::ii of legal mediclxe. the foregoing it ^viR be evident that it is qnite possible for a -woman ta be ignorant of the fact that she is pregUcint, or to be conscious that she is pregnant and be able to snccessf ally decei^'e the phvsician without disparagement to his skill and discrimination. Viability is the term which is applied to the susceptibility of an in- fant to sustain existence outside its mothers womb. It impHes a degTee of development sufficienth' advanced to sustain such an existence. A child is not mature or ripe until the normal termination of "pregnancy, but it is frequently capable of living and developing though born prior to maturity. Premature ehildi-en are of course more sensitive and deli- cate than those who have reached fiUl matiu-ity. but there are countless instances in which such children have surmounted such adverse condi- tions and lived to adult life or old age. The seventh month has usually been regarded as the earliest hmit of fetal viabiUty. and many who are born at that early period quickly succumb. The vital organs are suffi- ciently developed to permit the continuance of life, but unless the sui-- roundings are unusually favorable attempts to rear such feeble infants are usually futile. In recent years, and especially in France, the use of the couveme or incubator has resulted in the sa^ing of many prematiu-e or iinmatui-e children. The names of Tarnier and Auvard are promi- nently identified with this important work, and Auvard beheves that by the judicious use of the incubator the limit of vialiility may be set back as early as the end of the sixth inonth. The question of successfully continuing existence is quite different from that of merely showing signs of animation, such as gasping, mo^dng the limbs or even the body. Children who give such signs of life are qnicTi or li-sdng, in distinction from the stiU-born, who give no e-^T-dence whatever of life. Signs of life, though few and feeble, may be of the gTcatest impoi-tance from a legal standpoint. Cases are not infrequent, especially in the gynecological literature of the past few years, in which signs of Life have been shown at the sixth, fifth, or even fourth month.* Tlie absolute duration of gestation — that is. the exact time from con- ception to dehvery — is, for many reasons, a diifieiilt matter to determine in the great majority of instances. If a woman experiences sexual inter- course ever}^ day or' nearly every day it will be almost impossible in case of pregnancy to decide just when conception occuiTed. If sexual inter- unable to speak Euglisli, the tumor was supposed to l3e one reqtiiring extii-pation of the uterus. The preguauey was recognized when the abdomen was opened, and the patient prompt!}" recovered, also without abortion. In another case kno\^^l to the wi-iter a siu'geon of great experience opened the ab- domen on account of supposed ovarian tumor, mistook the pregnant uterus for such a tumor, thrust a trocar into it, and only then discovered his error. This patient also- recovered, and, it is believed, without abortion. * Coe's case of extra-uterine pregnancy, which was recently reported, is a verr remarkable one. The fetus was said to be between three and four months old. and after it had been removed from the mother's abdomen " it made vigorous movements of the arms and legs for at least three or four minutes, which were observed by several spectators." {Tran.mctious American Gi/necoloffical Sncicti/, 1S93. p. 271.) In Lusk's case of extra-uterine fetation the infant was well advanced in the sixth month. It lived twenty-six minutes after delivery from the mothers abdomen. It was between eleven and twelve inches in length, weighed twenty-fo^ir ounces, had fine hair upon its head, fat in the cellular tissue, but no lanugo or vernix caseosa. The eyelids were separate and the pupillary membrane stiU distinct. The nails did not reach to the tips of the fingers. {Traits. Amer. Gi/n. Soc, 1893, p. 263.) BIRTH, tSEX, I'L'EGXJSCy, AXD DELIVEUY. 4,31 course occnirs only at considerable intervals the date of etjiieeption ma}' be more ncai-ly ai>proxiniated. If ovulation invai-iably coincided -with menstruation, and occurred at no otlier time, the solution of the question would be facilitated. Some Avritci-s are of the opinion that ovulation may occur at any and all times, irrespective of menstruation : if this i^; correct the hal)it of dating- conception from the last menstruation is un- reliable. Even if the last coitus for a long period of time were assumed to be the fruitful one there would still be a chance of error, for the reason that a previous coitus might have been the fruitful one. If the last coitus were fruitful the exact date woidd still be uncertain, on account of the uncertainty as to the (XMnu-rence of ovulation, and also as to the activity and vitality of the sj^ernuitozoa. The microscope has shown that this vitality nuiy continue as numy as eight days, and as long as active mo- tion is apparent they are capable- of performing their function in fructi- fying the ova. None know better than the obstetrician that the habit of fixing dates for conception and labor is unti'ustworthy, for none suffer more annoyance and inconvenience as the result of such miscalculation. It is merely a method of guessing, for the premises upon which to base mathenuitically accurate calculations are wanting. The development of the fetus in nfero may be influenced by the same causes which influence puberty and menstruation, though of course not to the same extent. Such conditions are climate, race and family pecuKarities, the general state of body aud mind of the mother during the period of gestation, etc. The statements which women make concerning the data of theu* preg- nancies are not always to be relied upon, however timthful the intention of the individual may be. J. Veit (quoted by Wiuckel, he. cif.) observed the following variations in the duration of pregnancies in the same series of women : In 7 eases the variation was less than 10 days. " 4 " " " from 10 to 20 " " 7 " " " fi-ora20to40 " " 2 " " " more than 40 " " 1 case " " 64 " Schlichting, also quoted by Winckel, observed in 456 cases that the dura- tion of pregnancy varied from 240 to 334 days. Of several observers who have started from a common basis, their in- formation l.)eing assumed to be relialjle, and the basis being that the ovum of the last menstruation is impregnated, the duration of pregnancy being calculated from the flrst day of that period : Mattei found the average duration 265 days. Schlichting found the average duration 273.1 " Matthews Duncan foimd the average duration 278 " Waehs, Jr., found tlie average duration 279.87 " Lowenliardt-Ahlfeld foiuid the average dui'ation 281.6 " Winckel {op. cif., p. 94) made a careful study of more than 5000 cases of pregnancy in order to give expert testimony in regard to its dm-ation before a German court. In 70 of these cases the duration exceeded 300 days, and in 47 it exceeded 302. In one it was 314, and in another 318, days from the day of the presumably effective coitus to the day of de- livery. The conclusion of Winckel is in the following words : " The 452 ^ SYSTEM OF LEGAL MEDICINE. average duration of pregnancy is abont 280 days ; it may vary, liowever, from 24-0 to 320, and perhaps even exceed this latter limit, which is by no means so rare as was formerly supposed, for in 6.8 percent, the dura- tion is over 300 days." Sclu'oeder wisely says that a very large child, with evidences of un- usual development, vigorous voice, large frame, long liau', etc., does not necessarily mean an unusually prolonged gestation, for all these phe- nomena may be seen in immature children. Winckel narrates a case in which 310 days intervened between the last coitus and the birth of the child. The mother had been divorced from her husband on account of adulter}^, and additional punishment was sought by the husband by civil process. The possibility that the dura- tion of pregnancy, under lawful conditions, was 310 days could not be disproved, and this fact, together with the very large size of the child, led to the mother's acquittal. Protracted gestation exceeding even the limit mentioned in the fore- going statements may occur either in the intra-uterine or extra-uterine variety. In the former variety some unusual conditions may have caused the delay, such as abnormal rigidity of the uterus, undue absence of irritability in the uterus, absorption of the liquor amnii, or disease and death of the fetus. If labor does not occur within a short time after the fetus has reached maturity its death must follow as a consequence, and in this condition it is possible that it miglit be retained weeks or months, perhaps undergoing decomposition, or withering and shriveling without decomposition, or becoming converted into a hard, stone-like mass, called lithopa^dion from the abundant deposit of lime salts within its tissues. An inert mass of this character may be carried by a woman in her uterus for the remainder of her life, it may be delivered sponta- neously, or its delivery may be brought about by the efforts of the physi- cian. The last-mentioned course is always proper, and should be resorted to as soon as it is definitely determined that the child is dead. If the pregnancy is of the extra-uterine variety and should continue until term, that is, until the fetus is perfectly mature, false labor-pains may be experienced at that time. They are false because they do not occur in a uterus which is pregnant, and because delivery by the natiu-al avenues and means is impossible. Death of the mother may result from hemorrhage, or from septiceemia (blood-poisoning) in connection with the decomposition of the child, or she may have vitality sufficient to with- stand these or any other accidents in this connection and die eventually from some entirely different cause. The child may be converted into a lithop^dion, which was described in the preceding paragraph ; it may decompose and the firmer tissues eventually be discharged after ^^lcera- tion into the rectum, the vagina, or the bladder ; or it may be removed from the abdomen by surgical operation. Cases which illustrate all these possible consequences are recorded in recent gynecological lit- erature. The duration of pregnancy is insufficient when labor occurs before the fetus has reached maturity. This does not imply that a living child may not be born and be susceptible of development though it may be imma- ture in many respects. The facts which relate to this phase of the ques- tion have been considered in connection with viability, and the subject will be further discussed in the article on Abortion (q.v.). BIETH, SEX, rilEGXAXVY, AM) DELIVERY. 453 The deterniiuation of the period of pregnancy which has lieen reached in such eases is by referenc'e to tlie hist menstruation or l)y inspection of the fetus itself. The question of legitimacy of offspring must in many cases hinge upon the supposed dui-atiou of pregnancy, and it has been shown that this is a subject in which error is very liable to occur. Many States liave fixed legal limits to the duration of pregnancy, but it must be evident from the testimony which has been adduced that such limits are very fallible, and that adherence to them provides the opportunity for possible injus- tice. By Scottish laAV and bv the French Code 300 days is the legal limit allowed for pregnancy ; by Prussian law the limit is 301 days (note as exception the case quoted by Winckel in a previous paragraph). By English law no time-limit for pregnane}' is fixed, cases being decided in accordance with the evidence of medical experts and the moral and col- lateral aspects of each case. In this country great latitude is allowed. Two cases are quoted by Taylor, in both of which legitiinac}^ was ad- mitted, the diu-ation of pregnancy, counting from the last coitus, being 313 days in one and 317 in the other. (See Leishman's System of Mid- ^vifenJ, 1875, p. 181.) As it has been shown to be impossible to deter- mine with accuracy the exact dm-ation of completed pregnancy in any given case, this being a variable quantity, it may be shown to be equally impossible to state Avith exactness the point or extent of development which has been reached in any given case of incomplete pregnancy. It is quite possible, however, to answer such a question approximately, and thus satisfy all legal requii-ements. Reference to the last menstruation will usually be regarded as the most important limit from which to make the necessary calculations. The size of the uterus will also be of assistance in such calculations, and we may add, upon this point, to the suggestions alread}^ given, the convenient statements of Lusk, which are as follows : In the second month the uterus is as large as an orange ; in the third it is as large as a child's head ; in the fourth it is as large as a man's head and can be felt above the stjmjyJu/sis ^>»&/s; in the fifth the fundus is mid- way between the sj^mphj^sis and navel ; in the sixth it has reached the navel ; in the seventh it is two fingers' breadth above the navel ; in the eighth it is half-way between the navel and the epigastrium ; in the ninth it reaches the epigastriimi ; in the tenth (lunar months are considered) it sinks until its upper level corresponds with the situation at the eighth. (See cut from Lusk's Science cind Ati of Midivifenj, p. 113.) As the navel is not a fixed point and varies considerably in different women in its distance from the symphysis, Spiegelberg suggests that measurements be made from the SYmi)hysis as a constant limit. Lusk adds, however, that it must be remembered that the uterus is subject to variations ac- cording to the size of the child and the quantity of amniotic fluid. Spie- gelberg's measurements from the symphysis to the fundus at different periods are as follows : From the 22d to the 2Gth week 8^ inches. From the 2'2d to the 28th week lOi " From tlie 22d to tlie 30th week ll" " From the 22a to the 32(1 and 33d week. . lU " From the 22d to the 34th Aveek 12" " From the 22d to the 3oth and 36th week 12i " From the 22d to tlie 37th and 38th week 13' " From the 22d to the 39th and 40tli week 13i " 454 A SYSTEM OF LEGAL MEDICINE. AMf eld, whose work on the determination of the size and age of the fetus prior to birth {ArcMv fiir Gi/ndJcoIogie, Band ii., p. 353) is authority with the best recent obstetrical authors (Schroeder, Wiuckel, Lusk, et al.), adopts methods which are rather complicated for general use, and Lusk's Fig. 68. -Schultze's diagram, illustrating schematically the enlargem.ent of the ntems during the successive months of pregnancy. (Lusk.) criticism of them is that they show such variations in the size of children born in the same week of pregnancy as to somewhat impair theu* prac- tical vahie. Additional assistance in determining the period of gestation may be derived by reference to the date of quickening. This is said to occur usually at the eighteenth week of pregnancy, but allowance must always be made for variations from that limit. The measurements of Fan*e are regarded by many as very valuable, and differ from those which have been given by Spiegelberg. They would, perhaps, be seldom applicable upon the living subject ; neverthe- less they demonstrate the impossibility, even on the part of competent anatomists, of arriving at identical results upon such a question as this. The following are Farre's measurements of the pregnant uterus : BIliTH, HEX, riiKCXAyCY, AM) DELIVERY. 455 Length, Width, Inches. Inches. 3d montl 1 4 A to 5 4 4th " H " 6 5 5th " 6 "7 5A Gth " 8 "9 H 7t]i " 10 H 8tli " 11 8 9th " 12 9 If after the foregoing rules have been applied the utmost limit of ges- tation has been reached and no signs of labor are ajjparent, the suspicion will be warrantable that there is exti"i-uterine gestation, or that there is intra-uterine gestation and that the fetus has died. The former supposi- tion will be warrantable if a sound introduced into the uterus shows that the organ is only slightly enlarged if enlarged at all. If the latter supposition is the correct one there will be absence of fetal movement ; palpation of the uterus wiU show want of resiliency in the organ, and a sensation of bogginess or doughiness, while the patient will be conscious ■of an unconifortal)k^ feeling of weight or chilliness in the uterus, which is very diifereiit from the sensation which is produced by the presence •of a living cliild. IV, DELIVERY. Delivery and the Puerperal State — The Condition of the Genital Organs at the Time of DeKreri/, together tvith Evidences in General of Recent De- livery — Lorhial and Lacteal Secretions — Supposititious and Suppressed Children — Feigned Delivery — Duties of the Physician when the Conse- quences of Labor are LiJiely to Prove Serious to Mother or Child — Inter- vals between Successive Pregnancies — Evidences that Pregnancy has Existed at any Time — The Injuries of Parturition, their Frequency, Extent, and Possible Consequences — Duty of the Obstetrician in Recog- nizing and Treating Them — Responsibility of the Patient when the Physi- cian's Adviceis not Heeded — Questions Concerning the Duties of Physiciayis in the Presence of Conditions which Call for the Major Operations in Obstetric Surgery. Delivery or labor or parturition includes the phenomena associated with the extrusion of the fetus and the structures appertaining to it through the birth canal. It is divisible into three distinct stages or peri- ods, the first being concerned with the softening and dilatation of the tissues throngli wliich the fetus is to pass, the second with the passage outward of the fetus, and the third with the expulsion of the placenta or fleshy structure which has been the bond of union between the mother and the child, the medium through which the \'ital cm-rent, with its nutrient elements, has been comnumicated from the one to the other. With the placenta are also expelled the membranes or envelopes in wliich the fetus has been suri'ounded. Delivery at term signifies com])letion of development — the fruit, being ripe, drops, having no further necessity for attachment to the parent stem. If labor occurs before the fetus has matured it means, as in the 456 ^ SYSTEM OF LEGAL MEDICINE. analogous condition in vegetable life, unripeness and imperfection, with, possiljle harm to the stem from which it has been separated. Deliver}'-, like pregnancy, is a normal function, and when accomplished in a perfectly normal manner should give rise to no serious disturbance. Among many of our native Indian tribes the pain and discomfort asso- ciated with labor are insignificant. A woman may fall in labor while on the march : she stops awhile until the child is born, washes it in the near- est stream, straps it on her back, and then hurries forward to rejoin her comrades, who have not waited for her. In civilized hfe the best-con- ditioned, best-developed women bear children without great discomfort, though there are few who are entirely insensitive to the pain which ac- companies childbirth, especially when they experience it for the first time. Others who are weak and badly formed find the pangs of labor almost insupportable, and there are many whom death would claim as its victims, on account of absolute inability to bring forth their children, if art did not intervene and remedy nature's deficiencies. The obstetric art is essentially life-conserving ; it is more than that — it is life-giving ; and it was never practiced with such skill and success and discrimina- tion in any previous age of the world, by the profession at large, as are exercised now. To conduct a labor to a successful issue the physician must determine with reasonable accuracy the following facts : that the vitality of the mother is not being seriously encroached upon by the pain which she is suffering ; that the birth canal of the mother is of ample dimensions to permit the extrusion of the child at the proper time ; or, if the foregoing conditions are not satisfied, that the proper instrumentalities are at hand to reinforce the vitality of the mother, and to furnish a safe delivery, and, if possible, the safe delivery of the child as well. A physician is negligent who trusts to the unaided efforts of nature to efi'ect delivery when it is evident to one of ordinary percei^tion and experience that na- ture unaided cannot deliver, or can do so only at the gravest risk to the mother's tissues or life : the interests of the child, though important, are secondary, for many reasons, to those of the mother. A physician is negligent, when oi)erative measures are required, who does not call to his aid skill superior to his own for the performance of such operative measures, if his own skill and experience are insufficient, if such superior skill is available. Except under extraordinary conditions, a woman should not be allowed to die undehvered. Except under extraordinary circumstances, the life of a child should not be deliberately sacrificed by operative measures. A jjliysician should, in the great majority of cases, be able to discriminate whether the interests of mother and cliild are best sulisei'ved by the operation of version or by the use of the ol:)stetric forceps. A physician should be able to discriminate, with the assistance of counsel if necessary and available, whether the interests of motlier and child may not be best subserved by the performance of symphyseot- omy or Caesarean section. In view of all the resour-ces which modern obstetrics places at the command of the pliysician, including the pra(;tice of rigid asepsis, wliich is only anotlier term for cleanliness, there are few complications which place any case of midwifery beyond the reacli of efficient relief. After labor is concluded the puerperal state begins. It usually contin- ues four to six weeks, and is a period of very great importance, for it is BIRTH, SKX, PREGXASCY, AXD DELIVERY. 457 the period in which the uterus under«]roes iuvohitiou by means of contrac- tion and fatty dejjreneration of its muscular libers, the placental site be- coming obliterated, and by -vvliich restitution to the cc)ndition which it sustained prior to pregnancy is established. This condition is, however, never precisely identical with the contlition of a uterus which has never been unpregnated, the contour of the organ being somewhat more rotund, while its external orifice almost invariably declares to the prac- ticed eye or finger that the \-irgin state no longer exists. While the process in question is going on, especially in its early stages, the condi- tion of the woman is a very sensitive one. Within the uterus, and some- times in other portions of the birth canal if the labor has been a severe one, there is an extensive raw surface through which poisonous germs may be absorl)ed with great facility. It is the period in which the di'caded and dreadful inierjieral fever, which sometimes sweeps through communities like a pestilence, is a possible contingency. Only since the self-den^nng labors and sacrifices of the lamented Semmelweiss has it been appreciated that this disease is preventable if the labor has been properly conducted and strict cleanliness observed in all the siuTound- ings of the patient. This disease is practically unknown among savages and others who lead an out-of-door life. This is not, however, on ac- count of superior cleanliness or caution on theii" part, but because of the beneficial effects of an out-of-door life. In many matemits' hospitals in which puerperal fever once raged with terribly destructive effects it is now almost unknown. It is proper to reiterate the statement that a physician is negligent who does not observe the most scrupulous cleanli- ness in all his dealings with puerperal women. In ahnost all labors, especially the fii"st which women experience, the strain upon the tissues as the child leaves the birth canal is such that more or less tearing of them occiu's. Such injuries are ordinarily most marked at its outlet, and careful inspection will usually revejil then* loca- tion and extent. Their importauce cannot be exaggerated if we remem- ber that they often furnish the opportunity f«.>r septic infection; hence the necessity of treating them by means of suitable hgature mateiial as soon as possible after they have oeciu-red, thus anticipating any fm-ther injmy from such a soui'ce. The tissues in question may be torn in any direction, the mucous membrane of the vagina being torn longitudiually, transversely, or obliquely, or the mucous membrane of the vulva may be involved, or the injury may extend outward to the skin, or through skin, mucoiis membrane, fascia, and muscle, finally going thi'ough the rectum, or it nuiy extend upward and invade the bladder. The injmy may result in the detachment of the fascia by which the vagina is supported, without any apparent involvement at the surface. The uterus may be wounded to any extent, from a simple fissure at its external orifice to complete ruptm-e of the organ and delivery of the child into the abdom- inal cavity. It must therefore be plain that the accoucheur s duty has not ended when the fetus and its attachments have passed out of the mother s body and into the world. He should acquaint himself at the earliest possible moment after the conclusion of labor with the condition of the maternal tissues which have been subjected to such a severe strain. If this were always done as a nuitter of routine, much trouble would lie ob\'iated for patient and physician, and there would be fewer invalids fi'om such a cause. In addition to the e^•idences of recent deliverv from 458 -4 SYSTJiM OF LEGAL MEDICINE. the injuries, wliicli liave been alluded to, one may also observe swelling- and discoloration of the vagina and vulva, enlargement of the veins of the vulva and anus, and more or less prolapsus of one or both lips of the cervix uteri. In many cases there will also be paralysis of the bladder and consequent inability to pass the mine, which may continue several days after delivery. As soon as the contents of the uterus have been expelled there is im- mediate shrinkage or contraction of the organ if the course of events is the natural one, and instead of expending far above the navel it does not extend much higher than the symphysis pubis, its size being quickly re- duced to that of a small cocoanut. Thenceforward during the puerperal state or puerperium it continues to contract, as we have already remarked, until the normal unimpregnated size has been reached. In some cases the contraction is so excessive that a condition of atrophy is reached, the •organ becoming reduced to the size of a seckel-pear. This is the condi- tion which is known as superin volution, and it is usually followed by irremediable sterihty and the menopause. It is a rare condition, the writer having seen not more than four or five cases. In other cases the contraction is imperfect : the organ remains nearly as large as a base-ball for months, and is more or less lioggy to the touch. With it are associ- ated more or fewer uncomfortable symptoms, and unless another preg- nancy supervenes or the patient is placed under the most judicious treat- ment the condition will prove a very troublesome one. This is the con- dition which is known as subinvolution, and is a very common one. The abdomen, which has been greatly stretched during gestation, be- comes relaxed and flabby, and the more numerous the pregnancies, and. the shorter the interval between them, the less disposed the tissues to regain the tone and firmness which they had before pregnancy ever oc- curred. The skin of the abdomen shows furrows and striae and more or less pigmentation in testimony of the pregnancy which has recently occurred. The breasts swell and harden, and by the thu*d day after dehvery lactation is usually estabhshed. The wonderful sensitiveness of the mammary glands and the intense sympathy which they share with the rest of the genital apparatus, and especially with the nervous system, are seen in the frequency with which they become inflamed after delivery in response to any disturbance in the parts A\ith which they are in sym- pathy. Lochial and lacteal secretions are necessary concomitants of the puerperal state in normal cases, and, eonversel}', when they ai-e observed the obvious inference must be that the pregnant state has recently ex- isted. But it nmst not be forgotten that a bloody discharge from the vagina and milk in the breasts may occm' independently of pregnancy, while it is also possible that both may be absent though pregnancy and delivery have been recent. The lochial dischai'ge is composed of blood and broken-down tissue, and implies that the usual degenerative changes in the uterus are progressing. It usually continues three or four weeks, gradually becoming less abundant and more watery in character. It is a very important index to the physician of the situation within the ute- j'us, and if it suddenly ceases or becomes unusually abundant or very offensive it is a warning that the situation within the uterus is not a ■desirable or proper one, and a plain indication that interference is neces- sary. The lacteal secretion is susceptible of great variation as to quan- liiirni, si-jx, rnKdXJXcv, axd dklivert. 439 tity and quality, aud the pliy.sieiuii sliould Ije alert to discover the first evidence of disturbance in this direction, for it is then that the trouble may be averted or minimized. The suppositition or suljstitution of a cliild for fraudulent purposes is, of course, possible, especially if there has been collusion on the part of the jihysician or midwife. Cases ai'c recorded in which such a fraud has been practiced for the purpose of securing an iuheritance (see Wharton and Stille, vol. iii., sec. 87) ; but detection cannot be avoided if the signs of recent pregnancy and delivery are wanting in the supposed mother. There is no way of counterfeiting such signs, taken as a whole, which is known to the writer. The same may be said in regard to fe'ujned ddivery. Many women have deceived themselves and their attendants, either will- fully or unconsciously, during their supposed pregnancy, and have finally taken their beds in expectation of delivery. The possibility of such occiuTences demonstrates the necessity of diagnosticating the condition ■of a woman by means of a careful examination and not by the statements W'liich may Ije made, if one would preserve his reputation and liis self- respect. Suppression of a child after it has been delivered is possible either through accident or by design on the part of the mother. Cases are suf- ficiently numerous in which the mother has been suddenly taken in labor and has gone to stool apparently for the purpose of emptying her bowels : the child has been hovn and has perished from exposure, the mother returning to her household duties as if nothing had happened. It is possible to conceive that such cases and others of similar precipitate labor may occui' without criminal intent on the part of the mother, but the inference -in most cases will be that criminal intention was present. The obstetric art has made a distinct advance in the last decade in the treatment of cases in which labor v/as likely, according to former meth- ods of treatment, to prove serious or even fatal to the mother or the ■child, or to both. Unfortunately there are man}' women who are so de- formed as to theii' pelves, that it would seem impossible that they could be delivered of living full-term children by the uatiu-al process, it indeed they could be delivered of them at all. The alternatives are the destruc- tion of the clidd, with dismemberment if necessary, and deliver}- through the contracted natui-al passage, the induction of labor at tlu' seventh month or subsequently in the hope of obtaining a li\dng child, or the removal of the cliild at maturity through an opening in the motliei''s al)domen and uterus (Ca?sarean section), or the division of the bones at the symphysis (symphyseotomy). If the child is dead when the obste- trician takes charge of a given case it has no rights which ai'c to be re- garded, and it should be delivered in such a manner as ^\^)l offer the highest degree of safety and comfort to the mother, whether with instru- nu'uts or without them. But if the child is living it has natural and legal rights which nnist not be ignored. The Eoman Catholic Church forbids the deliberate sacrifice of the cliild, even though the life of the mother may, in all prol)ability, be saved thereby. There are certain con- tingencies in which the mandate of that church would be disregarded, especially if tlie obstetrician were not of that faith. If a child were manifestly feeble or deformed, or so constituted that it could not accord- ing to human judgment, survive, the obstetrician would be derelict if lie 460 ^ SYSTEM OF LEGAL MEDICINE. allowed its useless existence to jeopardize the life of its mother. But mere disproportion between the mother's pelvis and the dimensions of a living and presumably normal child would not, as a rule, be a valid ex- cuse for depriving- the child of life. If the mother is already in a dying- condition when the obstetrician arrives ui)on the scene, and the child is vigorous in its movements and has a vigorously acting heart, the ques- tion of quickly removing it by Caesarean section becomes pertinent. Such an operation has been done with the result of obtaining a living child. Of coui'se it requires not a little fortitude to undertake such an operation. The chances of obtaining a living child are diminished if Csesarean section is deferred until the mother has expired. Such opera- tions have also been performed : they are usually unsuccessful, for the vitality of the child is dependent upon vitality in the mother. The induction of premature labor at the seventh month, when the birth canal of the mother is not sufficiently capacious to allow the pas- sage of a fully grown child, is a procedure which is directed chiefly in the mother's interests. A seven months' child, as we have already stated, has not the vitality or the development of a full-term child, and there is not onl}^ the risk that a child thus prematurely^ delivered may not be liv- ing when delivered, but that attempts to rear it, if living, may be futile. The homes of the poor and careless, where such children most frequently come, are illy equipped for the painstaking efforts which are required by such feeble infants. The mother suffers less risk by such a procedure than by any other which has thus far been debased, and no unusual skill is required of the obstetrician for its performance. Of the two remaining measm-es suggested for the relief of unusual hindrances to delivery the indications for their employment differ. Sym- physeotomy enlarges the dimensions of the pelvis at its brim or inlet in all dii-ections, but particularl}" in its transverse diameter, through wliich the longest diameter of the fetal head usually first descends. The gain in this dimension may be as much as three quarters of an inch or even an inch. If by such an increase in area the birth canal might bec(3me sufficiently spacious for the passage of the child, S3anphyseotomy should be the operation of choice or election. The operation consists in divid- ing the tissues which cover the joint formed by the union of the two pubic bones, and then dividing the structui-es which hold the bones to- gether. The |)ressure of the child upon the structures of the pelvis being constant, as soon as the bones are di\dded the pehis expands like a hoop which has been cut and the ends pulled apart. This may give the addi- tional half inch or inch of space which will be necessary for the delivery of tlie child. Even when this has been done delivery is not always accom- plished Tjy the unaided efforts of nature, but a way has been opened so that if further use of instruments becomes necessary they can be employed with gi'eater advantage than before the operation. If the utmost space that could be gained by such a procedure still leaves the conditions unfavor- abfe for delivery the alternative must be Cassarean section, which signi- fies an iniision in the abdomen of the mother, another in her uterus, and removal of the child through the two openings thus made. The experi- ences of the past ten years have made this (qjeration relatively safe in- stead of almost iTiiiformly fatal as was formerly the case. It is the last resort, with its modificMtions, of obstetric surgery, and if performed upon a woman who has not been exhausted by ineffectual attempts at deliver}^ BIRTH, SEX, niEGXAXCY, AM) DELIVERY. 4G1 by other modes — that is, if made a matter of choice and performed at the most auspicious moment, which is usually considered to be the moment when labor has commenced — the chances for success for both mother and child are, as a rule, very good. A certain amount of skill is rc(juired in the performance of either symphyseotomy or Ca^sareau section, and this fact seems to be overlooked by many writers. It does not folhjw that one who is clever in the use of the obstetric forceps or in the perform- ance of manual version would be equally successful in performing s\'m- physeotomy or Ca'sarean section ; hence such operations will always ap- pertain to the specialist rather than to the general practitioner. A more exact definition of the scope of these operations is not appropriate to a work of this character. Their history has been very gratifying, since it includes the restoration to health and usefulness of many mothers and the rescue from certain death of mau}^ children. Not a few instances are on record in which Ca^sareau section has been repeatedly performed upon the same woman, the boon of living childi-en being thus accorded to many who could have them in no other wa}'. The number of children which a woman may have or should have is a question which cannot be answered in a general way. Conditions of law, physiology, and casuistry may all be involved in its consideration and may all conflict with one another. It is not generally appi-eeiated that an enormous number of the cases in which pregnancy occurs are abortive. Tliis fact has its favorable and its unf avoidable aspects. If all pregnancies resulted in the birth of living children it would be almost inevitable that overpopulation would quickly stare many communities in the face.* On the other hand, multitudes of fetuses are like blighted fruit, not having sufficient vitality to mature ; other multitudes are killed, murdered in nfero, and in the vast majority of cases neither those who commit the crimes nor tlieii* accomplices are ever brought before courts of justice, the rights of the murdered children being absolutely ignored. It was contended in ancient medical tradition that the pregnant state was the normal one for women, and certainly the anatomy of the endo- metrium, with its de^*elopment and degeneration during each menstrual cycle, would seem to sustain such a supposition. But it must never be forgotten that a pregnant woman has two existences to provide for — her own and that of the fetus which she is carrying ; and if her stock of vitality is insufficient to properly sustain herself, it is manifestly unjust to her to impose upon her the burden of sustaining herself and another : it is also unfair, or at least unfortunate, to her offspring that it should come into the world handicapped with an inheritance of physical debility. This is no plea for criminal aliortion, but a protest against ill-assorted marriages, unrestrained sexual indulgence, and failiu'e to guard against * This statement is made with due cautiou and resevvation because of the per- fectly oljvious fact that in many parts of the Avovkl conditions of climate, race, etc., are nnfavorahle to fecundity, even though abortion never occurred. Dr. F. A. Cook, ethnologist to the tirst Peary North-Greenland expedition, states that among the Esquimaux, Avith whom the impulses of nature are followed without restraint, abortion seldom occurs (though some of the women are sterile, and death during labor is :in occasional occurrence). Dm-ing the fifty years or more that these peojile have been under ol>serva,tion, though living under natural conditions and in surroundings to which they have become habituated, they have increased in numbers very slowly. It must be added that overpopulation is effectually prevented by their custom of kill- ing the helplessly aged, and infants whose mothers have died. 462 ^ SYSTEM OF LEGAL MEDICLXE. impregnation wlien enfeebled and diseased offspring must be an inevi- table consequence. After impregnation has taken place the attitude 'wliicli tlie physician should take toward the mother and her unborn offspring should be a •conservative one. He cannot tamper with life. Those cases only are excepted in which f ailui'e to terminate the pregnancy prematui*ely would almost certainly result speedily in the death of the mother, and, of course, of the child also. In the case of women who are suffering with serious constitutional disease, including pulmonary phthisis, ckronic neplmtis, syphihs, and ■diabetes mellitus, it is believed that pregnane}^ should be prevented if possible. It is hard thus to decide for those with whom the maternal instinct is strong, but it is better to suppress natural tendencies or self- love than- to work lasting injustice to others. If a woman is not debili- tated by disease and is of suitable physique for the requirements of pregnancy, parturition, and lactation, she will usually be benefited rather than harmed by impregnation occiu-ring as frequent^ as it may occur naturalty in the ordinary course of temperate married life. It will be understood that these statements refer only to the ph3'sical side of woman's life ; their bearing in other directions is not under consideration. Among our native American population, especiall}' among those who are provident and temperate, the number of children which a woman "bears rarely exceeds six ; usually it is under rather than over this number. Who can say that it is not better to raise and train carefully a small number of children, both with regard to the interests of the individuals themselves and those of the state, than to breed immoderately, with re- sulting deterioration of the offspring and defective bringing up ? Six pregnancies at intervals of two or three years will consume as much ^itality as the average American woman can spare for such pur- poses and at the same time do justice to the other duties of life. How- ever natural it may be for a healthy woman to bear children — and that is conceded — it certainly is not the first and only duty winch she has to consider. There are many indications or signs which declare to the eye of an observant physician that pregnancy is present or has been present in a given case. In the absence of these signs it is not well to affirm too positively that it has not been present. A woman's statements that preg- nancy has or has not existed at a previous time are useful only as they are eonfii-matory of a diagnosis which must be based essentially on the sight and touch of the phj^sician. The facial expression of a woman who has borne children is entu-ely different from that of one who has not. It is frequently alluded to as the matronly or the maternal expres- sion, and is easily caught if one compares the photograph of a girl who is just married with one of the same person with her baby in her arms a year or 'two later. Its description is almost impossible in words : some- times it seems to consist in a broadening of the face, an enlargement of the features ; sometimes there is a benignancy of expression which is entirely sni generis — the radiancy of maternity which the old Italian mas- ters incorporated in some of their madonnas. The breasts of one who has borne children are usually well developed, especially if the childi'en have been nursed. Functional activity tends to the enlargement of these glands as it does to that of any others \ but if the BIRTH, SEX, PREGNANCY, AND DELIVERY. 463 quantity of fat associated witli tlie glands is small the breasts may not be conspicuously large, though serving sufficiently well the object of lac- tation. The pa!pilla3 of the areoke of the breasts, also the nipjjles, are suggestive by their prominence and enlargement that pregnancy has ex- isted ; but the evidence derived from the breasts may be misleading, and it is chietiy of value when combined with other evidence. The scars, the folds, and the pigmentation of the skin upon the abdomen are also sug- gestive. They are sometimes lacking in distinctness, especially if a woman has borne but one child, or if the nutrition of her body is unusually good ; but they teR an almost unmistakable stoiy in women who have been pregnant several times, repeated stretching having destroyed the natural apx)earance of the skin and the ordinary contractile force of all' the tissues of the anterior abdominal wall. With regard to the e^ddence furnished by the appearance of the external genitals there may be little that is suggestive if pregnancy never proceeded to term, but if it had so proceeded the stretching and tearing associated T\-ith the delivery of the child would almost certainly leave behind some e"vidence as to the fact. If, however, the wounds which were made have been skillfully closed, determination as to the pre\dous existence of pregnane}^ may be almost impossible. The vaginal mucous membrane of one who has borne chil- dren is smoother, less rugose than it is in the virgin, the folds having been stretched or spread out. The vaginal portion of the cer^dx in the parous woman presents decided points of dissimilarity from the condi- tions in the vii-giu : it is larger, its extremity suggests the section of a cylinder instead of a cone (as in the virgin), and its os or external open- ing is a transverse slit of variable extent instead of a round opening. The last-mentioned fact has heretofore been considered a diagnostic point of unfading accuracy ia differentiating those who have been pregnant from those who have not. Since the operation of trachelorraphy has come into vogue, however, it has frequently been found difficult to de- cide from this sign alone in regard to the question of a pre^dous impreg- nation. From the foregoing statements it will be e\ddent that the cases ^\tII be rare and infrequent in which it will not be possible for a physi- cian of experience, especially if he has devoted considerable attention to the practice of obstetrics and gynecology, to state mth considerable pre- cision whether pregnancy has ever existed in a given case. If operations have been performed upon the pelvic organs the inferences therefi'om will sometimes be of value and sometimes they will not. The scar of an incision upon the abdomen may be an indication that Ctpsarean section has been performed, Init it may also indicate that an operation for dis- ease of the ovaries lias been performed, and if those organs were removed subsequent pregnancy would be impossilile. The scar might also indi- cate that an operation had been performed for appendicitis or any other disease of the abdominal viscera entirely distinct from disease of the genital organs. Scai-s upon the vagina or uterus might also signify* the performance of operations which had no relation to pregnancy. Testi- mony of this character is therefore necessarily inconclusive and indirect, and should not be accepted by a com*t of justice as evidence per se that pregnancy has existed. Oljstetrics or midwifery is indeed a well-nigh perfect art. A correct appreciation of its principles is more generally diffused than ever before, and there is scarcely a complication which can arise which is not suscep- 4G4 ^ SYSTEM OF LEGAZ MEDICINE. tible of successful treatment by those wlio are masters of the art. The number of those who have acquii-ed this mastery is increasing year by year. The obstetrician who practices in the cities is esj^eciall}^ conscious of these facts, because to the city hospitals the greater number of those who suffer from the accidents of parturition are brought for reparative treatment. The number of those who suffer from certain forms of these accidents is far less than it was a few years ago. Take, for example, the accident of vesicovaginal fistula, one of the most distressing in the entu'e category' of parturition injuries, resulting fi'om a severe or a badl}' man- aged labor. A few years ago our special hospitals were tilled with such suffei'ers : now thej^ are rarely seen. This must prove that midwifery and its sister-art, siu-gical gynecology, are more inteUigently and more successfully practiced than fonnerly. The question then arises. Why is it that so many women still continue to i3resent themselves for relief from the accidents of labor °? To this question several answers are possible. Fu'st, there are certain cases in which, owing to serious faults and defects of structui'e, injury' cannot be prevented, no matter how skillful or in- telhgent the obstetrician may be. Again, the labor may have been proj)- erly conducted and terminated, but siibsequent carelessness or injudicious conduct on the part of the j^atient may have led to conditions which could only be reheved by surgical measures ; or an unskillful midwife or even an unskillful or badly equipped obstetrician may have been responsible for the injury ; or, finally, bad results may have come about through no aj^jjarent en-or on the part of the ]^h5^sician or the patient, for reasons which cannot be explained. Unavoidable accidents from first labors are stm quite fi*equent and probabty always will be when the tissues have a tendency to tear rather than to stretch, as is so frequently the case when women do not become i^regnanfuntiL after they have passed their thirtieth year. The particular forms which these injui-ies may take have akead}^ been noted. It is well to reiterate the necessity that the obstetrician caref idly examine his patient after labor has been concluded and at once repair the damage as accurately and comj)letely as possible. There are cases in which the excuse for not following so %dgorous and thorough a line of ti-eatmeut seems entu-ely valid : the labor may have occurred at night, and in the imperfect light which was available an injury may have been overlooked ; or the cramped and contracted hmits and apphances of a tenement-house may have fm-nished obstacles wliich at the moment seemed insuperal^le ; or the patient may have been so exhausted by her .sufferings that additional exposure and pain even for a few minutes would have seemed unwarrantable. But whatever the excuse, whether valid or uivalid, it often happens that neglect to take the precautions mentioned results in infection thi'ough the wounded tissues, with subse- quent scaiTing and contraction, or in inflammatory disease of the uterus, with subsequent involvement of the o^dducts and ovaries. If the ipatient leaves her bed too soon, or is exposed to cold, or is not kept suificieutty clean, e^dl results may foUow for wliich the ph^'sician is in no way responsible, for he would not have aUowed the imprudence or the exposm-e if he could have prevented it. The mother of a family among the poor is often compelled b}^ stern necessity to take risks after her labor which a woman in more comfortable circumstances would never be subjected to. She is obliged to leave her bed and attend to her household duties long before she is in any condition to do so, and the BTJlTn, SEX, niEGNANCY, AND DELIVERY. 4(;r, penalty in many cases is a very severe one. Finally, no nnitter how skill- ful or intelligent the physician or the midwife may be, no matter how careful or how clean in their treatment, there is a certain iniml)er of cases which go wrong from the beginning, not only among- the ig-norant, the poor, and the careless, but among the well-to-do and the careful. In addition to the mischievous results of severe lal)or upon the structure of the genital and urinary organs, there are other morljid conditions affect- ing women who have been pregnant, which are sometimes secondary to and dependent upon those injuiies which they have received, and some- tinuis occur independently of or in the absence of such injuries. Malig- nant disease of any part of the body, which may liave been quiescent during pregnancy (though it frequently progresses jjari pofisn with the pregnancy), may assume a dangerous aspect and progress i-apidly to a fatal issue as soon as pregnancy has terminated. The same is true of tubercular disease of the different parts of the bod}', also of the chronic inflammatory diseases of the kidne3's, etc. One of the inost imi:)ortant grou})s of the morljid sequels of parturition includes the mental disorders, and these may occur with or without the surgical injuries before men- tioned. The mental derangement may take the violent form of mania in its varying grades, or the subdued form of melancholia, also of vary- ing degree. In a general way it may be said to be induced by the in- tense agony of parturition, manifesting itself in a burst of frenzy, tran- sient, disappearing with the conditions which excited it ; by preexisting tendency to mental disease, which matures either into occasional attacks of mania or into a prolonged period of melancholia within a few daj^s or weeks after pregnancy is over ; or by septic influences or material operat- ing during the period of pregnancy through the medium of the blood and lymph currents, or after labor has terminated. The subject of legal procedures against physicians in cases in which parturition has resulted unfavorably in one way or another is an interest- ing and most important one. Such procedures are usually most annoy- ing and vexatious, involving much time and expense, and, it may be, the very possiljility to the physician of living and working at his calling in the community where all his interests are located. Such interests nuiy have been built up by the laborious work of numy years, and it not in- frequently happens that they are jeopardized by those who should be attached to the x>bysician by all the claiiiis of gratitude and hunuinity. Let us see for a moment what are the phases of obstetrical practice. In the majority of cases it consists mainly in cleanliness on the part of all who are in an}'- way concerned, in not being meddlesome, and in " giving nature a chance." Such cases may be handled by intelligent mid^nves with perfect propriety. Other cases demand the exercise of good judg- ment, common sense, and a reasonable degree of mechanical skill ; they are bej^ond the sphere of the midwife, and should be attended by physi- cians of at least the average intelligence. The remaining minority of cases require the highest qualities of judgment and the highest degree of intelligence and mechanical skill — qualities which are possessed by but very few. The average ph^^sician, who has had no opportunity or train- ing in special lines of work, should not be held accountable for injmies resulting from supreme difficulties, nor for injuries which have resulted from the carelessness or imprudence of the patient, nor for those which liave resulted from her failure or unwillingness to comply with conditions 466 ^ SYSTEM OF LEGAL MEDICINE. wliicli Lie or one of greater experience and skill has deemed essential to her welfare. The law, which recognizes the physician's work as largely one of hu- mane effort, which exempts him from jury duty and other duties whick are incumbent upon the ordinary citizen, should shield him also from the attacks of mischievous and irresponsible persons in the matter of the discharge of his duty in behalf of partuiieut women. In consideration of the present status of the science and art of obstetrics, and of the oppor- tunities which are now widely diffused for obtaining the necessary infor- mation and experience in this direction, it may be boldly said that no one- who practices in tliis department should offer the plea of inabilitj^ to per- form the operations which are necessitated by the lesser accidents whick are incidental thereto. Certainly one who is incompetent to do suck operations is not a proper person to practice obstetrics, for we have seen, how important is their bearing upon the future weKare of the individual.. Besides, in isolated communities and sometimes even in the cities, the services of the skilled specialist are often quite unavailable, and unless, tke operations in question are performed at tke time tke injuries are re- ceived they are either not done at all, to the possible detriment of the indi- vidual, or they entail no little expense and annoyance by being done at a subsequent period, perhaps necessitating a prolonged absence from home. In the presence of the serious complications of midwifery — for ex- ample, such as require the opening of the abdomen, and incision, repair^ or removal of the uterus or other important structure — what is the duty of the average obstetrician with but little surgical experience or skill and no experience at all in suck supreme emergencies ? Tke supposition is, furtkermore, tkat ke is unable to call to kis aid tke skilled assistance necessary for suck an occasion. The condition is a dilemma either horn of which is disagreeable enough to take. Either he must attempt a seri- ous, delicate, and difficult operation for which he has neither experience nor fitness, with a bare chance of success if it is done properly, and the' certainty that it will make matters worse if not done proper!}^, or ke must fold kis kands and do uotking except enforce cleanliness and drainage^ witk tke possibility tkat nature may furnisk tke one ckance in tke pa- tient's favor wkick is necessary to overcome tke situation. Tke lesser evil would seem to tke wi^iter to be involved in tke expectant or do-notk- ing plan, and ke would tkerefore counsel against tke performance of tke operations in question by tke inexperienced. Tkere is no ckance of suc- cess in ignorant and kapkazard rusking into suck serious situations for tke sake of doing sometking, tke most tkat can be aceomplisked being to bring tke operative measures into discredit. It is better to do notking tkan to do sometking raskly and unwisely. It is better to kave tke con- sciousness tkat a patient died because one did not know kow to relieve ker tkan to feel certain tkat ske died because of tke injudicious violence wkick was inflicted upon ker. Tke performance of tkese major obstetri- cal operations must ever be limited to tke comparatively few, and tke part of prudence and wisdom will consist ratker in anticipating and pro- viding for tkese evils tkan in abortive attempts to remedy tkem witk means wkick are almost certain to prove ineffectual and disastrous. ABORTION AND INFANTICIDE. BY CHARLES JEWETT, A.M., M.D., Sc.D.. ABORTION. By the term abortion, or miscarriage, as used iu criminal law, is under- stood the unlawful termination of pregnancy at any period of gestation. The distinction observed in medicine between the terms abortion and pre- mature labor is not recognized iu law. An abortion is said to be com- plete when the entire product of conception is expelled ; incomplete when a portion of the ovum is retained in utero after the expulsion of the fetus. For the purpose of this discussion the subject of abortion presents two general subdivisions, non-induced and induced abortion, and under the latter head must be distinguished legitimate and criminal abortion. 1. NON-INDUCED OR SPONTANEOUS ABORTION. The frequency with which miscarriage occiu-s from innocent causes is variously estimated at from one in five to one in ten pregnancies. The causes of spontaneous abortion may be divided into two groups : 1. Those which act by first causing the death of the fetus ; 2. Those which act independently of the death of the fetus. B}' far the larger pro2)ortion of cases are included under the fii-st head. The fetus may die in consequence of malformation, tlisease, me- chanical violence — as falls or blows — maternal toxemia (e.g., carbonic- acid poisoning, saturnism, alcoholism, mercurialism, iodism, etc.), excess- ive anemia, pathological conditions of the chorion, the amnion, the cord, or the decidua. Old age or disease in the father is an occasional cause. On the death of the fetus the ovum shrinks, and, as a rule, is expelled within a few days or weeks as a foreign body. Under the second head are included reflex irritation of the uterus (as by stinnilating rectal injections, irritation of the maninuiry glands, and tlie like), emotional excitement, placenta^ pra?via, epileptiform convulsions from uremia or other cause, carbonic-acid poisoning, hemori'hages into the placenta, detention of the uterus in the pelvis by adhesions, dis- placements of the uterus, uterine carcinoma. In'dramnios. multiple preg- nancy, falls, or blows. Congestion of the pelvic organs due to cu-culatory obstruction in the lungs or liver, or to heart disease, violent nniscular effort, excessive coitus, etc., may result in hemorrhage into the placenta and consequent abortion. These causes operate ])rimarily to excite con- tractions of the uterus and thus the ultimate expulsion of its contents. 467 468 ^ SYSTEM OF LEGAL MEDICINE. 2. INDUCED ABORTIOX. (a) Legitimate Abortion. — Under certaiu conditions it becomes the duty of tlie obstetrician to terminate the pregnancy. As a general rule artificial abortion is justifiable when the mother's life would be jeopard- ized by the longer continuance of the gestation. The conditions in which it is most frequently called for are nephritis and uncontrollable vomiting of pregnane}'. In extreme contraction of the pelvis, and in certain cases of marked atresia of the soft parts of the parturient canal, the evacuation of the uterus in the early months of pregnancy is permissible, on election of the mother, where a Csesarean ojDcration would otherwise be necessi- tated if the case were allowed to go to term. It may also be called for in placenta pr^evia. The induction of abortion, when required for scientific reasons, should be undertaken only with the formal assent of another practitioner. The physician should always, for his own protection, associate with himself a competent consultant in the management of the case. Various measures have been used for provoking abortion. Among them may be mentioned the puncture of the membranes and the partial separation of the ovum by means of a uterine sound. These are more especially applicable in the early months ; later the passage of a flexible bougie, and the injection of glycerin, high up between the membranes and the uterine wall, are recognized methods. Repeated strong applications of faradism or galvanism through the uterus will usualty provoke abor- tion at any stage of j)regnancy. In the fii'st two or three months a good method in experienced hands is the dilatation of the cer"\TX and the ■evacuation of the contents with a curette and uterine forceps. A skilled operator can easily empt}^ the gravid uterus in this manner in fifteen to twent}^ minutes. (b) Criminal Abortion. — The measiu-es employed to procure illegiti- mate abortion are of two kinds, medicinal and mechanical. Medicinal Pleasures. — Abortifacient drugs act by dii-ectly or indii-ectly exciting uterine contractions. Among the reputed abortifacients are ergot, borax, cimicifuga (blacksnake-root), extract of cottonwood, sa%'in, rue, tansy, wormwood, apiol, yew, pennyroyal, digitalis, squills, quinine, belladonna, pilocarpine, sarsaparilla, hellebore, labiu-num, gi^ains of para- dise, guaiacum, sodium sahcylate, oil of amber, phosphorus, strychnine, broom-fern, lignum vitae, hoarhound, camomile, mugwort, cantharides, juniper, juice of bamboo leaves, milk-hedge, and other euphorbiaceous plants, chii^etta, molline, carrot seeds, sassafras, arsenic, corrosive sub- limate, cyanide of potassium, sulphate of copper, iron, and drastic purgatives such as aloes, croton-oil, elaterium, Epsom salts, gamboge, liierapicra, and pilacotia; carbonic dioxide, bisidphide of carbon, and illuminating gas, by inhalation, are also recognized abortives. Some of these preparations act directly to induce contractions of the uterine mus- cular fibers ; such agents are known as ecliolics. Others act on the vascular system. With very few exceptions, these di*ugs are capable of causing abortion only when the ovum has an insecui'e attachment, if at all. Wlien they operate promptly, at least in ordinary doses, it is to be presumed that there was a predisposition to miscarry. Of the foregoing agents only a few requii'e special mention. ABOllTIOX AM) IXFAXriCIDE. 4G9 Ergot. — This sul)stanee is a nioi-Lid growtli sometimes found on tlie seed of rye and certain other grasses. The ergot of rye [Si'cale coniufiini) is that most commonly employed. Ergot has the power to intensify uterine contractions alread}' begun. That it can originate them de novo, during the lii'st half of pregnane}', is considered doubtf id ; yet I have occasionally seen evidence of its influence as an ahortifacient, even in the early months of gestation. The dose of the crude drug is from one- half to two drams, of the fluid extract, from one to two fluid drams, three times daily. lu extreme doses ergot gives lise to toxic effects. A sense of heat and dryness of the throat, pains in the stomach and bowels, nausea, and sometimes diarrhea are the principal symptoms. Occasion- idly there is marked retardation of the cardiac movements, vrith. headache and vertigo, delirium and coma. The pupils are usuall}- dilated. Ergot in powder has a faint, fishy odor which is especially developed by rubljing with a solution of potassic hydrate. The same odor is mani- fest on mixing the caustic potash solution -v^-ith the tincture of ergot, when free from the odor of other substances. When ergot has been taken in powder the drug may usually be recognized by the microscope as small red particles deposited upon the mucous membrane of the stomach and iutestiues. Tansy {Tanacetumvnlfjare). — In our own country, especially, this agent has a popular reputation as au abortive. The oil and the infusion are the preparations most frequentty used. Fatal results have followed the ingestion of a half-oimce of the oil, and even smaller quantities. In a case mentioned in the United States Dispensatory, death resulted from a large dose of the infusion taken internally. The toxic symptoms con- sist of irregidar respiratiou and extreme cardiac depression, with, finally, violent convulsions and coma. Abortion does not necessarily oecm-. Cotton-root (root of the Gossypium herhaceiim, or common cotton- plant). — The tincture or decoction of the bark of the root has acquii-ed the reputation of an abortifacient, and is said to be used for this pui-pose among the colored race of the Southern States. The latter statement, however, has lieen denied on the authority of reputable Southern practi- tioners. Savin (the tops of the Juniperus sahina). — The oil is the most active preparation. The fluid extract is nearly as effective. The powdered leaf is sometimes employed, as are also the infusion, the decoction, and the tincture. The medicinal dose of the powdered leaf as an emmenagogue is ten to fifteen grains, of the tinctm-e one-half to one dram, and of the oil five minims. The toxic effects are severe pain, caused l)y its irritant action upon the stomach and intestines, with vomiting and diarrhea, and finally colic and convulsions. Salivation and hematm-ia are also com- mon results of the ingestion of toxic doses. Its action upon the uterus is probably secondary to its violent systemic effects, and the tb-ug is accordingly an exceedingly dangerous agent when used in quantities sufiicieut to produce abortion. It can be said to have no specific power as an abortive agent. The oil is recognized by its yellowish color and the characteristic odor of the plant. It is solul)le in ether, and may be recovered from the C(m- tents of the stomach by shaking them in a flask -with this agent. After death by saviu-|»oisoning the odor of the di'ug is sometimes perceptible in the tissues of the body. 470 ^ syste:u: of legal medicine. Eiie {Rufa graveolens). — Preparations of rue have a decided action; upon the utenis. Most used are the powdered leaf, the essential oil, and the infusion. The medicinal dose is one-half to one dram of the powder, fi'om one to five minims of the oil, and from five to thii'ty grains of the leaf in infusion. In toxic doses it produces vertigo and is a power- ful vascular depressant. The tongue heconies swollen and the patient suffers from salivation, nausea, severe pain in the stomach, jactitation, stupor, and chiUs. The abortive effects of the di'ug are usuallj^ developed only after marked sj'stemic disturbance. The contents of the uterus are, as a rule, expelled on the second day after the onset of the toxic symp- toms. Tew {Taziis haccata). — Abortive properties have been attributed to the fi'iiit of the yew-tree, but in all recorded instances of its use for the purjiose. death has taken place without evacuation of the utenis. Saffi'on {Crocus safivus). — The stiginas of the satfi-on flowers are a popular abortif a cient; but theii' reijutation as a uterine excitant appears to have no foundation in fact. PennjToyal {Hedeoma pulegioides). — The warm iirEusion, pennjToyal tea, is a much-used emmenagogaie in domestic practice. Its re]3utationr however, as a means of provoking the mensti'ual flow is not well founded. Its mention here would be unnecessaiy but for the fact that active aborti- facient properties have been erroneously attributed to it in a noted case' in the criminal coui'ts of Cireat Britain. Drastic Cathartics. — Aloes, croton-oil, elaterium, colocynth, and other- violent pui'gatives may act as reflex uterine excitants. Hiera-picra (a combination of caneUa bark, one part, and aloes, four j^aris) and pilacotia (a mixtru'c of coloc^Tith and aloes) are sometimes employed as abortives. This class of agents are of httle effect as abortif acients except hi condi- tions which predispose to miscarriage. Apiol is an emmenagogue of undoubted power. It exerts a dh-eet effect upon the circulation of the uterus. It is therefore capable of ex- citing abortion under fa^'orable circumstances. The tinctiu'e of the chloride of h'on has been given in large doses with the intent of producing abortion. While it is caxiable of deleterious effects upon the general health when used in large quantities, it has no specific action as an abortifacient. Meclianical Measures. — Mechanical measures are far more effectual abortives than drugs. These means ma\', after the first two or three months of gestation, be such as act by fii'st causing the death of the fetus. Thus the child may be kiUed b}^ blows upon the inothei*'s ab- domen. Generally direct "siolence to the abdomen produces abortion by disturbing primarily the relation of the ovum to the utenis. The at- tachment of the ovimi to the uterine wall is jiartially broken up, with the effect to bring on expulsive efforts of the uterus. Under this head are included blows on the abdomen, intentional falls and muscular strains, caiTiage-riding over rough roads, bareback riding,. long walks, tight-lacing, vaginal or uterine douches, and direct inteifer- ence by other means within the uterus. Tents of sponge, sea-tangle, or similar material are probablj' seldom used by criminal abortionists. These instruments consist of small, compact pencils of sponge of wood about two inches in length, which possess the property of expanding when moist. Placed in the canal of the uterine neck they absorb water ABOUTIOX AM) IXFASTIVJDE. 471 from the sniTOiiiidiii^ structures, aud, swelling-, tliey dilate the cervix. The ovum is i)artially separated from its attacliments at the lower seg- meut of the uterus, and becoming in part a foreign body, the uterus con- tracts to expel it. The methods most employed are some forms of direct interference. The ovimi nuiy be partially detached from the lower uterine segment by means of a sound or probe, or it may be pei-forated. In the first method the curved uteiine sound is passed between the membranes and the ute- I'ine wall, and the memljranes peeled up l)y sweeping the point of the sound around the circle. Uterine contractions may thus be set up gen- erally within a few hours. When abortion is induced by penetrating the membranes a blunt probe or pointed instrument is passed through the neck of the uterus and the membranes perforated. This operation is done by the professional abortionist and sometimes by the patient her- self. The attempt is less likely to be successful in proportion as the stage of gestation is early and the ovum small. Among the instruments that have been used for this purpose by the woman herself may be men- tioned knitting-needles, pieces of wdre or whalebone, stilettos, hairpins, penholders, l)ougies or catheters, and wooden skewers; sometimes the finger. The professional abortionist generally employs a uterine sound or some similar appliance as a perforator. On puncture of the mem- branes the liquid contents of the ovnm escape and the ovum collapses, the uterus retracts, partially separating the product of conception from its attachments to the uterine wall, aud a greater or less amount of hem- orrhage occurs. The embryo or fetus dies from beginning interruption of the uteroplacental circulation and other causes, and the uterine con- tents become a foreign body. As a rule contractions of the uterus are soon established, and it exj)els its contents generally within a few le by the second month. By this time, too, the veins over the surface of the breasts have beconjc turgid, and by eh^se insi)ecti()n may be seen coursing across the primary areohi?. After the third month a milky serum may generally be pressed from the nipples. Practically all these (ihanges may occur as the result of pelvic disease, whi<'h, thercfoi-e, must be excluded. Evidence Afforded by Stains upon the Bedding or Clothing. — Blood discharged from a woman in case of abortion is practically indis- tingaishable from human blood derived from other sources. Meconium stains present certain distinctive characters by which they may usually be identified. This material is a dark- greenish, viscous liquid yielding the reaction of bile to the nitric-acid test. With tincture of iodine a green coloration is produced. Among its microscoj^ical elements- are intestinal epithelium and crystals of cholesterin. (Plate VI., Fig. C.) In case of abortion in an advanced stage of pregnancy vernix caseosa may be found on the i)atient's linen or bed-linen. This material may be identified by its microscopic and chemical characters. The microscope reveals epidermic scales and lanugo. The presence of fatty matter is demonstrated bv shaking ujd the particles with ether, which extracts the fat. (Plate VI.; Fig. B.) POST-MORTEM SIGNS OP RECENT DELIVERY. All the clianges in the maternal organism which may result from pregnancy should be looked for. The evidence of recent delivery, how- ever, is to be found mainlj^ in the condition of the vagina and the uterus. The vagina is increased in size, and, after delivery in the later months of pregnancy, its outlet presents the wounds or cicatrices characteristic of recent childbirth. The uterus is enlarged according to the stage of gestation wliich had been reached and tlie degree of involution which had taken place. Immediately after delivery at term the uterus measures externally 7 or 8 inches in length, and 4 or 5 in width at the level of the Fal- lopian tubes. The thickness of the walls is about \h inches. The depth of the cavity is at the close of labor G inches ; at the end of the first week about 4.J inches ; at the end of the second week Z]^ inches ; and al)out 3^ inches at the expiration of a mouth. The fundus uteri, shortly after labor, lies at the level of the umbilicus ; by the tenth day at the pelvic brim. The average weight of the uterus at the close of a fuU-term labor is 35 ounces; at the end of the first week, 16 ounces; at the end of the second week, 12 ounces ; end of the third week, 8 ounces. The uterus does not usuaUy fully regain its normal dimensions for nearly two months. The regressive process is somewhat slower in nndtipara^ than after first labors. The cervix remains relaxed and soft after labor, begin- 476 ^ systjlM of legal medlcixe. iiiug to regain its form and consistence after about twelve hours ; two fingers can be passed tlu-ough the os internum at the end of twenty-foiu' hours. At the expii-ation of a week the cervical canal admits one finger. Dii'ectly after dehvery the canity of the uterus is still lined with the outer layer of decidua and ^vith shreds of the inner layer. The placental site presents a shghtly elevated and uneven sm^faee studded with thrombi lying in the mouths of the uteroplacental vessels, winch have been torn across b}^ the separation of the placenta. More or less fluid and clotted blood is jDresent in the ca^dty. The muscular fibers of the full-term uterus ai'e from seven to eleven times longer than in the normal state of the non-gi'avid organ, and are increased in thickness. These changes in the uteras will have receded in proportion to the length of time that has elapsed since confinement, and will vary, too, "with the degree of pre- matnrity of the bii"th. The presence of a coi-pus luteum in the ovary is not distinctive of pregnancy. A corpus luteum is found whenever an ovum has been recently discharged from the ovary. It is always to be observed during the fii'st two or three weeks after menstruation. It reaches a higher degi'ee of development dm-ing pregnancy and does not disappear for several weeks after childbii-th. The absence of the usual corpus luteum of menstruation in its recent state would be e^ddence that a period of at least many weeks had elapsed since the last menstrual flow. AT WHAT STAGE OF GESTATIOX HAS THE ABORTION TAKEN PLACE ? The stage of pregnancy at which abortion has taken place must be estimated from the measurements of the uteiiis, and from the size and development of the fetus when the latter is available for examination. The following table shows the dimensions of the uterus while it still contains the li-^dng ovum, at different periods of gestation : SIZE OF THE UTERUS. Stage of Gestation. Lengtli. Width. 3d month. 5 inches. 4 inches 4th a 6 5 " 5th ii 7 6 " 6th 11 8i 6i " 7th a 10 7 " 8th 11 Hi 8 " 9th ii 13 9 " 10th a 14 10 The measiu'ements of the uterus are considerably diminished after ex- pulsion of its contents, yet the foregoing figures may serve as a guide in estimating the period of pregnancy at which a miscarriage has taken place. The nuUiparous uterus is nearly 1 inch in thickness, l-i inches in width at the fundus, aud 2^- in length ; it weighs about 1 ounce. The parous uterus in the non-gTa"\'id subject is approximately 1 inch thick, 2 inches wide, and 3 inches long, and its weight is 1.^ ounces. The uteras at the close of labor at term weigiis about 35 oimces. Aiioirrios AMI iMAMiriDi:. 477 Development of the Fetus. — The length, weif>'lit, and development of the fetus at different .stages of gestation are as follows: At the end of the first lunar month the diameter of the ovum is f of an inch. The ehorial villi are developed over the entire sui-faee of the ovum. The eml)ryo measures ^ of an inch in length and weighs 15 grams. The nose and mouth form one cavity, the abdomen is still open, the umbilical vesicle persistent, and the mendjers are indicated l>y mere })a})illa3. At the end of the second month the ovnui is 2h: inches in diameter ; the chorionic villosities have l.)egun to disappear over two thirds of its surface. The length of the endjryo is 1-^ inches, and its average weight is 1 dram. The mouth and nose are sej^arate and the al)domen closed. The umbilical vesicle clisa,ppears. The meml)ers are formed, but the fingers and toes are webbed. Ossification is beginning in the inferior maxilla and in the clavicle. At the end of the third month the diameter of the ovum is 4 inches. The placenta is formed. The embryo is S^- inches in length and weighs 1 ounce. The fingers and toes are separated; the sex is discernible. There are points of ossification in the bones of the skull and the limbs. The length of the umbilical cord is 2i| inches. At the end of the fourth month the fetus measiu*es 5 inches in length and weighs about 3 ounces. Hair begins to appear ; the sex is clearly apparent ; nails begin to be formed. At the end of the fifth month the length of the fetus is 9 inclies, and its average weight 9^- ounces. The umbilical cord is about 1 foot in length ; its point of insertion, instead of being at the symph^-sis as it is till the fourth month, begins to move upward. Meconium is present in the intestines. Vernix caseosa appears for the first time. Ossification begins in the ischium. At the end of the sixth month the fetus is 12 inches in length and weighs about 23 ounces. The cord measures 14^ inches. Ossification begins in the pubic bones. At the end of the seventh month the fetus is 14 inches long and weighs about 2^ pounds. The average length of the cord is 16^ inches. Ossification has begun in the astragalus. E^T:DENCE of CREVnNAL ABORTION. It will seldom be possible to determine by examination of the pelvic ■organs, the fetus, or its appendages whether the al)ortion has been spon- taneous or the result of criminal interference. When the operation has been clumsily done the marks of violence may be sufficiently ol)vious in the living patient, and especially on examination after death, to estab- lisli the fact that criminal measures have been employed. The obvious presence of disease in the membranes or placenta would point to the probability that the abortion was spontaneous. In criminal abortion the product of conception is more likely to be mutilated than entire. The history of the woman's illness shoidd be carefull,y analyzed for the toxic symptoms of the medicinal agents commonly employed for producing abortion. In post-mortem cases the contents of tlie stomach and bowels should be examined for evidence of the presence of abortive 478 ^ SYSTJEM OF LEGAL MEDICINE. dinigs. The abortive agents of tliis class which are usuaUv employed are generally capable of recognition b}^ their niicroscoj)ic or chemical char- acters or by experiments upon animals. EVIDENCE THAT COXFINE^IENT HAS AT SOjME TDIE TAKEN PLACE. It may devolve npon the medical witness to distinguish between the pa- rous and the nulliparous condition — in other words, to determine whether the woman has ever been confined. The signs are general and local. The j)igmentary changes which take place upon the breasts and abdo- men during the first pregnancy remain in a measui-e permanent. They are usuall}^ well marked in brunettes, but not so in women of light com- plexion. Moreover, they are not wholly reliable as evidence of pregnancy^ since similar changes may occur as a result of pelvic disease. The irreg- ular whitish, pinkish, or bluish lines which are developed over the lower half of the abdomen after the sixth month of pregnancy, once formed, are never effaced. They are also produced by abdominal enlargement to the same degree from other causes, yet this source of error raQ.j be easil}^ ehminated. The principal signs are to be sought in the condition of the organs immediately concerned in the pregnancy and the birth. Cicatrices of old lacerations may be found about the vulvar orifice. The presence of true carunculae myi'tiformes may be taken as evidence of childbii-th. This condition must be distinguished, however, from mere rupture of the hymen. The carunculae consist of four or five small, fleshy excrescences skirting the vaginal orifice, and which represent the remains of the h^onen torn by the birth of the child. After delivery during the fii'st half of pregnancy the condition of the hpnen would not be sufficiently char- acteristic to be of value as evidence that confinement had taken place. The vulva and vagina are more relaxed in the parous than in the nulliparous woman. Vaginal cicatrices may result from labor. Reliable evidence of previous childbirth is usually afforded by the condition of the cervix uteri. The lower border of the uterine neck is always more or less notched, and sometimes deeply fissured, after labor at or T^•ithin two or three months of term. The uterus remains permanently larger. Whether the number of confiuements which have taken place is one or more cannot be determmed 1\v the j^hysical signs. It is seldom possible to decide whether an abortion has at any remote time occm-red in the early months of pregnancy. The signs are fewer and less perfect^ developed than after delivery in the later months, and the solution of the question is the more difficult the earlier in pregnancy the abortion has taken place. FEIGNED ABORTION. For the pm'pose of incriminating others a woman may simulate abor- tion. Taylor relates a case in which a Avoman in Guy's Hospital accused a policeman, who, she alleged, had ravished her, of having procured an abortion by means of drugs which he had administered and by the use of local mechanical measures. On examination by a medical expert, two months after the alleged miscarriage, no evidence was found that she had ABORTION AM> I M'AM'iri Dil. 47(> ever ])een prej^uant. Pi-iinarily ^rave doubt, as the author observes, is cast ii[)on a chargt,^ of tliis kind wlieii so h)iig' dehiyed after the allej^ed fact. Of interest in connection with this subject is a case of assumed abortion which was recently l)rought to public notice in Brooklyn. A gynecologist of recognized al)ility and unblemished reputation was ar- rested on the charge of criminal abortion. The woman, who had become ill during his treatment, joined in the accusation, under the belief, which was shai-ed by her usual medical attendant, that she had miscarried and was about to die of peritonitis. On examination 1)y the waiter she was found to be still pregnant, at about the second month, with no evidence that violent measures had been emploj^ed. On investigation before the coroner the gynecologist, whose treatment was show^n to have been en- tirely innocent and proper, was fully exonerated. INFANTICIDE. The term infanticide as used in medical jurisprudence appUes to the murder of a new-born child. In the vast majority of cases the crime is coTumitted at birth or directly after. It is immaterial, however, whether tlie age of the child is measured by minutes or days, since, under our law, "it is equally murder to destroy the life of a child which has been completely born as it would he feloniously to kill an adult." Nor is it necessary that the child shall have reached the full term of intra-utei-ine development, pro^dded it has lived after its bu-th. It mast, however, have been fully expelled in a living condition. It does not matter whether the cord has been divided or not ; the child is born when it has been completely expelled from the maternal passages even though the cord be still intact. It may have been born alive even though it had never breathed. Death takes place only when the heart ceases to beat. The destruction of a child in ntero or in course of birth is not infan- ticide. The law assumes that every new-born child has been born dead until the contrary is proved. The burden of proof that the life of the child has been willfully destroyed is cast upon the prosecution. This is a benefi- cent provision of the law to prevent unjust con^•iction, and is rendered necessary by the fact that a large number of children are at birth dead or non-vicil)le. It will thus be seen that the problem presented to the medical jurist in a case of alleged infanticide is l\v no means a simple one ; sometimes it is beyond the reach of medical e^'idence. Adopting the scheme of Ogston, the questions which confront the expert are the following : 1. Has the prisoner been recently delivered? 2. Was the child inature ? 3. Was it the child of the prisoner? 4. Was it dead or alive at its l)irtli ? 5. If alive, what was the cause of its death? 480 ^ SYSTEM OF LEGAL MEDICIXE. 1. HAS THE PEISONER BEEX RECENTLY DELRT:EED ? The facts upon Trhicli tlie solution of this question -vrill depend have "been ah-eady considered under Abortion. The question may arise in this connection whether a woman who has just been coniined could be ignorant of the fact. That a woman may give bu'th to a child without knowing it and without having recognized the existence of pregnancy is scarcely to be presumed. She may, how- ever, be unexpectedly delivered. In very rare cases the labor is practi- cally painless, and the child may be born before the mother is aware that the labor has actively begun. Again, the termination of the bii-th is frequently abrupt : the child is sometimes expelled from the uterus into the world in a single pain. This is more hkely to occm- if the wom- an is in an upright postm-e. A child expelled while the mother is in a standing or sitting position may sustain serious injury by precipitation upon the floor or into a water-closet. Yet simple falls are seldom fatal : the distance is short and the fall may be partly broken by the cord. Unintentional precipitation of the child into a water-closet or priws^ vault may easily happen and is not an extremely rare occui-rence. The pressure of the presenting part of the fetus in the lower portion of the birth canal usually gives rise to a \dolent rectal tenesmus. The sensa- tion is mistaken for an ui'gent demand for stool. Eesponding to the seeming necessity, the upright position of the partmient, and the strain- ing, help to precipitate the birth, and in this way it can happen that the child may be di'opped into a water-closet consistently with the entire in- nocence of the mother. Unconscious delivery is of eoiu'se possible iti eclampsia, in coma from whatever cause, and under aneesthesia. 2. WAS THE CHELD ]\LA.TURE ? The probability of natural death in the new-born is gTcater in propor- tion to the prematurity of the birth. The medical witness will therefore be required to testify to the probable stage of intra-uterine development which the child had reached. The following are the data upon which an approximate estimate may be given in the last three mouths of fetal development. For the rate of fetal gTOwth in the preceding months the reader is referred to page 477. At the eighth lunar month the average fetus measures IG inches in length and weighs 3.J pounds. The nails are fully developed, but do not project beyond the finger-tips. Lanugo begins to disappear from the face. At the ninth lunar month the fetus is, approximate^, 17 inches in length, and its weight about 4 pounds. . Lanugo is beginning to dis- ai)pear from tbe Iwdy. The ossific nucleus in the lower femoral epiph- ysis first becomes visible. At the tenth lunar month, the period of fuU maturity, the height of the child is from 18 to 20 inches. The measure is to he taken from the vertex to the lower border of the calcaneum. The a^^erage weight is 7 pounds. The principal head diameters, subject to certain modifications due to molding when measured shortly after birth, are as f oUows : The bipari- ABORTIOX AND IXFAXTICIDE. 481 etal, measured tlirough tlie parietal eiuiueiices, 3^ iiiclies ; the fronto-iuen- tal, from the summit of the forehead to the center of tlie h)wer mai'^nu of tlie chin, 8.i inches; the occipito-frontal, from the tip of the o('('ii)ital protuberance to the root of the nose, 4J inches ; the occipito-raental, from the tip of the occipital protuberance to the center of the lower margin of the chin, 5| inches ; the suboccipito-bregmatic, from the junction of the nucha and occiput to the center of the breg-ma, 3^ inches ; the l)item})oral, the distance l)etvveen the lower extremities of the coronal sutures, 3^ inches ; the bimastoid, the greatest distance between the mastoid ai)Oijhy- ses, 2| inches. The length of foot is 3J inches. Tlie average weight of the new-born child is from 7 to 7^ pounds. Both weight and measurement are slightly greater in male than in female births. The face and body are plumj). The cluld suckles and cries Instil}'. Vernix caseosa is j^resent chiefly on the child's back and on the tlexor surfaces of the limbs. The skin lies in deep folds at the flexor surfaces of tlie joints. Portions of the integument, especially about the shoulders, are thickly covered with lanugo. In full-term children the skin is whiter than in those prematm-ely born. The epidermis begins to be thrown off on the second day. The exfoliation commences on the abdomen, spreads over the body and lower part of chest, and is complete in about two weeks. The location of the umbilicus is above the center of leug-th of the child's body. If the child has breathed, the thorax is arched and the diaphragm depressed ; if respiration has not taken place, or only imper- fectly, the chest is fiat. The iinger-uails project l)eyond the finger-tips, the toe-nails to the end of the bed of the nail. The cartilages of the nose and of the ear are firm. The cranial bones are hard, the sutiu'es and the fontanelles small. Ossification is beginning in the upper epiphysis of the tibia and in the cuboid bone. The ossific nucleus in the lower end of the fenmr has reached the diameter of neaily or quite ^ of an inch. Ossification to this extent in the lower epiphysis of the femur may be taken as conclu- sive evidence of term-development. This bony nucleus appears as a small, distinctly marked, briiiht-red spot in the white cartilage. It may be much sniaUer or entu-ely wanting even in term-births. Hartmaim failed to find it in 12 cases out of 102. The examination t)f the epiphysis for determining the stage of ossifi- cation should be conducted as follows : The knee is slightly flexed and the joint laid open. Several horizontal sections are then made through the epiphysis. The dimensions of the bony nucleus may thus be readily determined. Its greatest diameter at term, which is the transverse, is from 2 to 5 mm. {>( inch). When only portions of a dismembered body are at the disposal of the expert, his conclusion must be based on the evidence of development afforded by the bones. Measui-ements of the bones are liable to be mis- leading, yet may furnish presumptive evidence. The stage of ossification is more conclusive. The femur and the inferior maxilla, as we have already secMi, afford valuable data. Not only the ossific nuclei but the papilla? of the molars should be examined. The latter become crowned in the last weeks of fetal devel- opment. The germs of the teeth do not solidify dui"ing iutra-uteriue life. 482 ^ STSTIJM OF LEGAL MEDIC IXE. The measiiremeut and weiglit of certain portions of the body and the "weight of ^dscera afford nsefnl guides for determining the stage of de- velopment. The follo\^^-ng figures are given on the authorit}^ of Letoiu'- neau : The distance from the pubis to the top of the head in a new-born child at term is about 12 inches. The distance from the pubis to the internal condyle of the femiu* is 2 inches; fi-om the latter point to the lower border of the calcaneum, 4^ inches. The distance from the acro- mion process to the epicondyle of the humerus is 3J inches ; from the latter point to the styloid process of the radius, 2f inches. The Aveight of the right lung is 8 drams and 15 grains ; of the left, 7 drams. The heart weighs 3 drams and 45 grains ; the liver, 22 drams and 45 grains ; the brain, 5 J ounces; the kidney, 2f drams. The size of the placenta, too, has an approximately constant relation to the development of the fetus. At term it is from 7 to 8 inches in width, and its average weight is 1 pound. The a^-erage length of the uml")ilical cord is 20 inches ; the length varies, however, fi-om 7 to 60 inches. While the foregoing may be regarded as a fair statement of the facts in the great majority of eases, some latitude must be allowed for varia- tions in individual instances. The weight and measurements of the child, especially, are subject to deviations fi'om the above-given figures in a certain proportion of cases. Occasionally a child born at full term may be considerably below the standard in point of weight and size. This is generally true of twins. Phenomenal instances have been reported in which the length of the new-born child was 22 and even 24 inches, and its weight 23roportionately excessive. Even the extraordinaiy weight of 25 pounds at birth has been recorded. New-liorn children, however, of more than 10 or at most 11 pounds are exceedingly rare. As a rale each succeeding birth of the same mother is larger than the preceding births. Xotwithstanding these occasional excejDtions to the general rule of size and weight, the sum total of the data available in a given case is sufficient for a definite opinion with reference to the stage of fetal development. 3. WAS THE DECEASED THE CHH^D OF THE PEISOXER ? The medical e^ddence bearing on this question will depend on the solution of several other questions : {a) Has the woman been recently delivered ? (b) How long a time has elapsed since delivery? (c) Did the child live after birth, and if so, how long? {(l) How long has it been dead? The facts relating to the fii'st and second questions have been dis- cussed under Abortion. The other questions are considered below. 4. WAS THE CHILD DEAD OR XLWE AT ITS BIRTH? {^tate of the Lungs. — Piihnonarij Docimasia. — The most valuaT)le evi- dence for determining whether the child lived after biith is afforded l\v the condition of the lungs. Before the first respiratory act these organs are devoid of air. As a nile the child breathes for the first time only ABORTION AND INFANTICIDE. 483 after its complete ex])iilsioii from the maternal passaj^os. Not infre- quently, however, resj)iratoi'y movements Ix'^in duT-inji' the l)irth. Wliile it is g'enerally possil)k^ to (letri-miue l)y examination (»f the liiu^-s after death whether or not tlu; eliild liad liivatlicd, these orle for more deaths in utero or soon after birth than iiny other fetal malad}'. It may be either of nniternal or of jjaternal or- igin. When the mother is sypliihtic every ovum cast off from the ovary is probaljly affected with the disease, and the child which is developed from such an ovum is syphilitic. If the father be syphilitic it is believed by many authorities that tlie spermatozoa contain the active cause of the disease and convey syphilis to the ova which they impregnate. When the mother is infected at the time of the fruitful coitus, or shortly before, the child is invariably syphilitic. Frequently, thougii not uniforndy, it develops the disease when the maternal infection is contracted during the pregnancy. In something less than fifty percent, of syphilitic cases the pregnancy terminates in abortion. A large proportion of the children die in utero in the later months of gestation. Only a small percentage of those born alive long survive the birth. In children born dead from this cause, the recognition of the disease is usually not difficult. Among the most conspicuous lesions of fetal sj-pli- ilis are osteochondritis l)etween the head and shaft of the femur and other long bones, and enlargement of the liver and spleen. On examining the cartilage which separates the diaphysis from epiphysis in the long bones and especially at the lower end of the femur, the line between bone and cartilage, instead of being narrow, clean-cut, and shaii^ly defined, as in health, is found wide and irregular in shape and of a yellowish color. The liver is enlarged to one twelfth, frequently to one eighth, the body weight. Asphyxia. — One of the commonest causes of still-birth is asphyxia resulting from prenuiture attempts at pulmonary respiration. It is to be remembered that during intra-uterine life the respiratory function is per- formed by the placenta, after l)irth by the lungs. So long as the placental functions are perfectly performed, the child has no need of pulmonaiy respiration, and makes'no effort to breathe. If the placental functions are wholly or partially susp(mded, respiratory nu)vements are provoked by the air-hunger thus developed. This may occur before l)irth from com- pression of the und)ilical cord, ])remature detachment of the placenta, partial or complete, ])rofuse heuK^rrhage, and from undue compression of the placenta by violent and persistent uterine contractions. If the first"^ attempts at respiration take place in the absence of air while the head is still in the birth canal, usually liquor amnii, blood, vaginal mucus, or meconium is drawn into the trachea and bronchi. 490 ^ SYSTEM OF LEGAL MEDLCIXE. Access of ail- to the alveoli and the lungs may thus be prevented after' bii'th. The essential element in the asphyctic condition is the venous stasis- superinduced in the thoracic cii'culation \>j prematiu-e respii'ator}^ efforts. On expansion of the thorax in the fii'st respiratory movements the capil- laries of the lungs are filled hj force of aspii'ation. In the absence of aii-, blood stasis is developed and congestion of the entu-e mtrathoracic venous- circulation. A secondary venous congestion is frequently developed in the general cii'culation. Prolonged compression of the brain during spontaneous labor in narrow pelvis, or liy the forceps in artificial extraction, may retard and arrest the action of the fetal heart in the absence of attempts at respi- ration through irritation of the pneiuuogastric nerve. For a full expo- sition of the pathology of asj)hyxia neonatorum the reader is referred to- Lusk's Science and Art of Midicifenj. The appearances found after death by asphj^ia are described under Infanticide by Suffocation. Accidents and Injuries. — The new-born child may die from accidental injui-ies sustained at the time of birth or soon after. Cases are frequently reported in which owing to unexpected dehvery the child has fallen upon the floor or has been expelled into a water-closet. Injuries sustained by falls OAving to sudden expulsion of the child in dangerous places, as has been ah-eady stated, are not often severe enough to be fatal. Precipitation into a privy vault exposes the child not only to mechanical injimes but to the dangers of drowning, or of suffocation by noxious gases. In laceration of the umbilical cord death may take place from hemorrhage. Bouehut cites a case in which a stout cord had parted during dehvery by forceps and the child had bled to death before biith. Yet the division of the cord without ligature is by no means necessarily followed by much bleeding. The funic stump is less likely to bleed when torn than when cut. Umliihcal or other hemorrhages may occiu* with a fatal result from other causes than non-ligation of the cord. Even when the funis is securely ligated, persistent and uncontrollable hemorrhage may take place from the umbilicus and from other regions of the body, owing to hem- ophiHa or other causes. In hemorrhage due to placenta pr^evia, or prematui'e separation of a normally placed placenta, the child is frequently born dead or in a non- viable condition from asphyxia. In difficult breech extraction fatal injm-y may be done to the cervical j^ortion of the spinal cord. In instrumental labors the fetal mortality is increased. Intracranial injuries may arise from compression of the head in difficult spontaneous births, especially in narrow pelves. In delivery in the absence of the physician the child is sometimes suf- focated from lying with its face in a pool of blood and liquor amnii. In very rai-e instances the child is born mth the membranes unbroken. This occurrence is much less frequent at term than in ^^remature de- livery. Though alive at birth, T\athout interference the child dies by suf- focation. The chest expands in the effort to breathe, but no air can enter the lungs. Deaths of new-born children from overlying are occa- sionally reported, the mother rolling over unconsciousl}' upon the child in her sleep. It is the duty, therefore, of the medical jurist in passing upon a case ABOnriOX AM) IXFJXTICIDE. 4artly in the uterus, the respiratory function would have been maintained through the placenta, and strangulation would at that time be impossible. Again, if the child had died in the act of birth little or no air w<.)uld be found in the lungs by the usual test. Nearly the same ar- gument would apply in refutation of the claim that the child had died ■during birth from the winding of the cord about the neck. Furthermore, it is very rai-ely that the coiling around the neck, when accidental, is suf- ficiently tight to strangulate the cord. Infanticide by Precipitation into a Privy Vault. — Infanticide by precipitation into the vault of a privy must be distinguished from cases in which the body has been deposited in the priv}^ after death for the pur- pose of concealment The presence of night-soil in the air-passages and stomach may generally be regarded as evidence that the child was living when it was placed in the vault. If it, be claimed that the woman, un- aware that the birth was so near completion, had innocently expelled the ■child into the water-closet, the medical facts should accord A^dtli this ■explanation. If, for example, the cord be found to have been cut instead of torn the defense will be discredited. In some instances a close inspec- tion of the ends of the divided cord may be requii-ed to determine whether it was sundered by incision or by laceration. The post-mortem appearances usuallv present after death by drowning should be looked for. Infanticide by Drowning. — The methods of child-murder most com- monly employed are those already discussed. Drowning is a mode of in- fanticide but seldom practiced, yet a case is mentioned in which a woman caused the death of her child by getting into the bath-tub partially filled with water, as the birth was about to be completed, and forcibly holding the head under water. Accidental drowning, as already stated, nuiy result from sudden and unexpected delivery, by the expiilsion of the child into a privj^ vault. Not uncommonly the body of the child, after destruction by other means, is thrown into the water for the purpose of concealing the evidence of crime. In all cases of drowning it is extreuu4y difficult to determine by the medical evidence alone whether death was due to accidental or crimiual causes. In case of alleged drowning careful search should be nuide for marks of violence such as obtain in other homicidal nu^thods. The body should be examined for proofs of suffocation or strangiilation, and for other evidence of violence, accidental or criminal. The fauces and 494 ^ SYSTEM OF LEGAL MEDICIXE. tracliea should be searched for obstrueting material wMch may have been placed there with criminal intent, as well as for the usual causes of asphyxia by accident in the new-born. The j^resence in the stomach of hquid or other material like that contained in the vault would be proof positive that the child was li\"ing when thrown into it. These substances could have gained access to the stomach only by the act of swaUowing. In the dead body they could go no farther than the mouth and nares. Infanticide by Wounds. — When wounds are found on the body in eases of alleged infanticide, the medical witness will be called upon to testif}" whether or not the existing wounds were comj)etent to cause deaths and whether they were inflicted upon the living child or were post-mortem injuries. The first question will be determined on general medical grounds by the location and extent of the injury. To answer the second is some- times dilEcult. Discolored patches upon the skin should be dissected to- disting-uish ecch^^noses from the simple blue coloration which is commonly seen about the Hjjs and nose of the new-born after death. Wounds re- sulting from labor usually occupy the presenting part of the fetus. Yet the death of the child may result from luxation of the cervical vertebrae in unskillful delivery. Abrasions, ecchymoses, and even lacerations of the skin, are frequently found after difficult births, even in the absence of instrumental interference. Wounds inflicted during life are usually distinguished by the e"^idence of hemorrhage, and, if the child lives sufficiently long after the infliction of the injury, by signs of repaii- or of inflammatory action. Apparently insignificant wounds, and even so small as to escape any but the closest scrutiny, may be fatal where \\tdl organs are involved. The wound may pass undetected when the puncture is made tlu'ough the mouth, the navel, the orbital canities, or other natui'al openings. These cavities, as well as. the f ontanelles and the surfaces overlying other ^dtal organs of the body, should be carefully scrutinized. In death by extensive wounds the body may jjresent the marks of extreme anemia from, acute hemorrhage. In case of susj)ected comj^hcity of the medical attendant in the crime, the fetus and the pehis should be examined for e\'idence of any condition that may have justified the mutilation of the child. Fractures of the Skull. — Fractures of the skull in the new-born are not' necessarily e\'idence of homicidal "\aolence. They sometimes occur from accidents of difficult or precipitate labor. It is not always possible to distinguish fractui-es produced after from those occurring before death. A distinguishing mark in post-mortem fractures is the almost complete absence of bloody effusion. This is always present in such injuries when sustained during life. '' Extravasation indicates movement of the blood toward the part affected."' In case of wounds inflicted a sufficient length of time before death, tlie signs of inflammation will be observed. Fract- ures fi-om the pressiu-e of the peMc walls upon the head during the birth are of extremely rare occurrence. Such cases, howeA^er, have been re- corded. Depressions of the skull by the sacro-vertebral promontoiy in deformed pelvis are situated on the anterior part of one parietal bone or on the frontal or the temporal near the parietal. They are seldom fatal. Skull fractui'e in the new-born from other causes than criminal, as has been seen, ma}- result from unexpected delivery while the woman is in the standing postm^e. A full liistory of the confinement wiU ob\dously ABOBTWX AND INFANTICIDE. 495 form an essential part of the data upon wliich the conclusions of the expert are to be based. Infanticide by Neglect. — Under this head are to be mentioned expos- ure to cold, starvation from willful omission to feed, and purposely neg- lected aiicidents. Examination after death resulting from exposure to cold will reveal nothing pointing specifically to the fatal injury, yet it will be important for the purpose of deciding whether or not an explanation of the dcatii may be founded on other grounds. In death from this cause the lungs contain air, showing that the child had breathed. The body presents no marks of violence. The entire absence of food in the digestive tract would raise the question of death by starvation. Death would not occur from the latter cause alone in less than a week, and the body would be greatly emaciated. The child may die of asphyxia from willful neglect to remove the tightly coiled funis from the neck ; it may purposely be allowed to lie with its face in a pool of liquids discharged from the bii'th canal; or umbilical hemorrhage may proceed to a fatal termination in consequence of omission to tie the cord. Even the failure to obtain medical aid in asphyxia, con- vulsions, or other maladies of the new-born, when they terminate fatally, must be classed among the criminal causes of death if willful neglect can be proven. GENITO-UEINAEY AND VENEEEAL AFFECTIONS IX THEIE MEDICO-LEGAL EELATIOXS. BY F. E. STURGIS, M.D. In the article whicli has been assigned to me I propose to consider the affections of the geuito-iu'inary organs in men and women in their bearing npon the marital relation, and the resnlts which venereal diseases — and by these I mean gonorrhea and s^^hihs — have upon the bearers of the diseases as well as upon theii* offspring. To properly discuss the effects of these diseases in their medico-legal relations I projDOse to divide them into the following gi-oups : First. Impotence in the male. Second. Impotence in the female. Third. Sterilit}^ in the male. Fourth. Sterility in the female. Fifth. The effects of gonorrhea in its sexual relations; and Sixth. The effects of sj^hilis upon the bearers of the disease and upon the children which may be born to them. My portion of this article wiU be entii'ely confined to the medical side of these affections. Impotence in the Male. — This affection is due to two causes, one pliysical, the other psychical, the first having its origin entirely in some physical malformation or physiological perversion, congenital or other- wise, and the other depending upon mental distiu'bances or impressions, whether originating from without or within the patient's mind. The physical causes are the ones which I shall first examine, and those of the penis are the foremost to invite attention. Sometimes there is a congenital absence of the viiile organ, while all the other parts are more or less perfect (entii'ely apart fi-om any ques- tion of hermapliroditism), the man being in perfect health, with all the external symptoms of ^drility such as are apparent in the face and in the contour and shape of the body. The scrotmn is present, with the testes in their normal place, but at the spot where the penis should be nothing is apparent. The urethra, in these conditions, usually opens behind the scrotum, in the perineum, as a small opening concealed by a fold of skin, sometimes seated behind a little excrescence, looking like a cockscomb, and comnninicates directly with the bladder, simulating somewhat the appearance of tlie fenuile meatus. It will l)e noted that in this case there can be no question of hermaphroditism. There is no appeai-auce 497 498 -4 SYSTEM OF LEGAL MEDICINE. -or simulation of any of the female genitalia, the subject being, to all intents and piurposes, a man, except that he has no penis. Sometimes, however, the condition of things does not go qnite so far as entire absence. In this case the malformation may be simply in the diminutive si^e of the penis, which varies from half an inch to two inches in leng-th, and is capable of more or less complete erection, unless it be tightly bound to the scrotum. Under such cii'cumstances the subject need not necessarily be impotent. He is capable of intromission within a cer- tain distance, and, pro"\dding the ejaculation of the spermatic fluid be com- plete, the man may be the father of a family. Excessive smallness of the penis is not, therefore, a bar to the completion of the sexual act nor to the exercise of marital duties ; but the condition is different in those cases known as a palmate penis — that is to say, where the penis is adher- ent to the anterior raphe of the scrotum and where it is then bound down, mechanically, during any attempts at erection. This condition of affans is, however, easily remedied by freeing the penis, when the jjhysi- ological functions of the organ are restored to then- normal condition. The opposite condition may also act as a bar to the sexual act, where the penis is inordinately large — and I do not mean enlarged from ele- phantiasis, but where the whole organ seems to be abnormally and equally developed, and where intromission into any ordinary vagina is impossible. Under these circumstances the man, although capable of complete erection and of the performance of the sexual act, is impotent from the disparity between his genitals and those of the average woman. Another cause of masculine impotence is due to the fact that the penis is sometimes double for a greater or less extent of its length, each organ ha^ing its own urethra. These unite posteriori}- into one canal and one i^enis, finding theii' termination in a single Ijladder, both organs from their point of bifurcation emitting two streams of equal size during micturition and being capable of double seminal emission. Under such cu'cumstances it is possible that a man may have connection, as is noted in the case of a patient reported by Isidor G-eoffroy St. Hilaire. This man, it is stated in the report, never engendered anjiihing but twins. This last statement I do not claim to pass judgment uj)on, as it seems to me, unless two ova were deposited in the uterus at the same time for fecundation, that it would make little difference how many virile organs entered the woman at the same connection. Another reason for the non-performance of the sexual act is due to a curious malformation which has been noted by many writers, viz., that at some portion of the penis a deposit occui'S in the corpora cavernosa which prevents the complete distention of the organ. Sometimes this results from calcareous deposits, from inflammation (gonorrheal or sim- ple), or fi'om an injury done to the organ by ''breaking a chordee,'' as it is called, and sometimes from s^^^hihtic exudations. Where it results from gonorrhea or syphilis it is, as a rale, curable, but where it is caused by \dolence or injury done to the canal, or where it occurs idiopathically, little can be done by treatment, although some cases are reported to have recovered spontaneously. Under these circmnstances the penis is turned either to one side or the other, or, as I have seen it in one instance, where the exudation was annular, one half of the penis remained entirely flac- cid wliile the posterior half was erect. Intromission and sexual inter- course are usually impossible, although if the jjenis be merely twdsted, GENITO-URINABY AND VENEREAL AFFECTIONS. 499 -while erection is comjjlete, coitus, witli a little maiia^emont, may be accomplished. Again, besides these path()h)'e ; most certainly as loii^ as Ik; has auy purulent (lischarj>e, or as long as there are any gonococci to be found in the (liscliarge. Many a man, after his clap has lasted for several weeks, has notliing to show except a little mucus or a slightly pundent dischai-ge in the morning. Dm ing the daytime nothing is ai)parent and there seems to be no trouble whatever. Sexual connection, if moderately in- dulged ill, seems to produce very little diistnrbiuice. The partner of his amorous joys is free tVom disease until the man, excited perhaps with wine or from whatever cause, overdoes the business, converts what was a comparatively innocuous discharge and mncous in character into an. active and purulent one, and then the woman suffers. It is just suck instances as this whicli make it difficult for the surgeon to determine how soon a man may resume his m.irital duties with safety to his wife, the i)atient being importunate in tluit respect in order to avert suspicions whicli perhaps hav-e alrc^ady been (^xcited by his abstinence from his duties. Under these circumstances, it becomes exceedingly difficidt, supposing that the wife contracts some disease, to be able al\va_ys to determine as to whether its origin be leucorrheal or simply gonorrheal ;. first, because so manj^ women suffer with "whites," and secondty, because the discharge in the patient may be of the very slightest and apparently mildest character. It is under these conditions that the microscopic examination for the gonococci becomes of importance and will go far toward establishing the verdict against the num ; but it sometimes hap- pens that gonococci are not detected, and then there is nothing left but the Scotch verdict of '^ non-proven." The results of gonorrhea in both male and female play a direct part in the medico-legal relations of the sexes during marriage. The most notable of these in the male is the inflammation of the epididymes, which produces blocking up and occlusion of the vasa defcrentia, which lead from the testes into the urethra, and of which I have already made men- tion when speaking of sterility in the nuile. This inflammation does not lead to any difference whatever in the man's power or capacity for cojiu- lation, and so far as his sexual strength is concerned neither he nor his wife can see any difference ; the only thing, perhaps, which attracts attention is that whereas, antecedent to his gonorrhea, he was fruitful and capable of impregnating his wife, after his attack no children are born. This statement must, however, be modified by the proviso that for complete sterility to ensue the epididymitis nuist have been double, that is to say, l)()th testicles nuist liave been attacked. If one only is at- tacked and the other one is sound, the man is sti'll fruitful, but of course he is injured in so far as he has only one sound testicle instead of two. I*rostatic liypei'trophy, if it lie chronic and continuous, may produce sterility by compressing the ducts which lead into the urethra from the testes, but this condition is mf Divorce Laws, 57. ■' t PMUps vs. AUvH, 2 Allen's Rep. 454. 520 ^ SYSTEM OF LEGAL MEDICINE. mill because the parties were not of sufficient capacity to contract, or for fraud in procuring it. Legislative divorces, by a special statute passed to meet the particular case, are also granted by some States in exceptional instances, for other than the ordinary statutory causes.* The United States have no laws regulating divorces, except as to per- sons belonging to the District of Columbia. In some States provision is made by law for the intervention of a public prosecuting officer to make defense in uncontested divorce suits, when he thinks such a course demanded by the public interests. Causes of Divorce Antecedent to the Marriage. — Want of sufficient age, or of mental or physical capacity, or relationship within the prohib- ited degrees, are causes of divorce antecedent to the marriage. So also is fraud in procuring the contract. The term " fraudulent contract " is sometimes used to denote only marriages where one of the parties is im- potent, thus defrauding the other of one of the expected advantages of the union ; or where both are so related as to make the contract one in fraud of the law.t But while these are cases of constructive fraud, there may also be- those of actual fraud. To constitute a cause of divorce for actual fraud,, the fraud must be plain and the proof clear. Fraud is never presumed. An unchaste woman commits no legal fraud in marrying a man who is ignorant of her character. If, however, she mairies when actually preg- nant by another man, and the husband was ignorant of her condition and believed her chaste, he can claim a divorce on the ground of her f raud4 It is otherwise if he knew that she was unchaste, though he did not know that she was with child.§ Should she, however, while in this, condition, under false representations of her chastity induce him to en- gage to marry her, and then entice him into sexual intercourse before and in contemplation of the marriage and for the very purpose of pre- cluding him from afterward claiming a divorce, because he would then have married her knowing by his own act that she was unchaste, such active fraud on her part, coupled with her pregnancy, would be sufftcient to give him a divorce. || Divorces on the Ground of Impotence, — On an application for a divorce on the ground of impotence, the court may require the defendant to submit to a surgical examination, unless this has been done before the institution of the action, and the result can be shown by proper testi- mony. A certificate by the examining physician is not receivable in lieu of his appearance as a witness.^ Long and unexplained delay on the part of the petitioner in seeking a divorce will bar the remedy. Ignorance of the existence of the defect will not excuse the delay, if there was the means of knowledge, and a. want of reasonable diligence in seeking to obtain it.** * Maynard vs. Hill, 125 U. S. Rep. 190 ; Starr vs. Pease, 8 Coun. Rep. 541. t Benton vs. Benton, 1 Day's Rep. 114. X Scott vs. Shitfelt, 5 Paige's Rep. 43. ^ Crehore vs. Crehore, 97 Mass. Rep. 330. II Seilheimer vs. Seilheimer, 40 N. J. Eq. Rep. 412 ; 2 Atl. Rep. 376. ^ DevenhaghYS. Bevenhagh, 5 Paige's Chan. Rep. 554 ; LcBarrou vs. LeBarron, 35 Vt. 365. ** Newell vs. Newell, 9 Paige's Chan. Rep. 25 ; B n vs. B n, 28 Eng. Law and Eq. Rep. 95. MARRIAGE AND DIVORCE. 521 It is not necessary to prove impotence generally, and as to all women. It is enough to establish its existence so far as the intercourse with the petitioner is concerned. A failure to consummate the marriage after three years of c<)lial)itation is presumptive evidence of impotence.* Causes of Divorce Arising after the Marriage — Insanity — Cruelty. — We have already seen that loss of 2)liysical power, occuiring after the marriage, is no ground for a divorce. The same is true in most States as to loss of reason, even if a i)ennanent affection, though this is some- times, in such jurisdictions, made the subject of a divorce by a special act of the legislature.t It is not a cause of divorce on the ground of '' intolerable ciiielty " that a husband insists on sexual intercourse against the wishes and re- monstrances of the wife, although, in consequence of her physical con- dition, this is indelicate, iiyproper, unreasonable, and injurious to her health, unless he knew that her condition and health were such as to make the act unreasonable.t If he had such knowledge, his acts would violate his marital obligations. There is a duty of forbearance on the part of the husband at the reasonable request of the wife, as well as a duty of sul )mission on her part at his reasoiuil^le request.§ The willfid. communication of venereal disease by one party to the other may amount to such an act of cruelty as to justify a divorce ; and knowledge of the existence of the disease on the part of the party affected may be inferred from the mere fact of its existence. It is not " cruel and abusive treatiuent " within the meaning of divorce statutes for a wife to refuse for years, without cause, to have any sexual intercourse with her husband.] | The old law of England gave a remedy in such a case, by a suit for the "restitution of conjugal rights,"' result- ing in the punishment of the offending party by imprisonment for con- tempt of court, should the refusal be continued after a judgment in favor of the petitioner ; but this proceeding was founded on principles of eccle- siastical law, applicable to courts having in view the preservation of the morals of the parties before them, and acting pro salute animcB. Divorces for Ili=treatment Injuring Health or Endangering Rea- son. — In some States divorces are gi-anted for acts which, though not amounting to extreme cruelty in the legal sense, yet are such as seriously to injure the health or endanger the reason of the other party. In applying such laAvs the temperament of the sufferer is to be re- garded. The health or reason of a feeble or neurotic person might be ■endangered by such a slight degree of ill-treatment as would have httle or no eifect on a healthier subject. Divorce is not intended as a pun- ishment of the offender, but as a relief to the j)arty against Avhom the offense is committed.^] If a man compels his \\'ife to submit to sexual intercourse so fre- quently as to impair her health, it mil be a sufficient ground of divorce, under a law of this character.** * A)i()in/mniis, 22 Eng. Law and Eq. Eep. 637. t See Cooler's edition of Blackstoue's Commentaries, vol. i., p. 441, note 23. I Shair vs. Sliair, 17 Conn. Kep. 189. v^ M((iiJicw vs. M/n/]ic)r, 61 Conn. Rep. 235. II Cni'rlrs vs. CoirJrs. 112 Mass. Kep. 298. ^ R(>hi)iso)i vs. liobinsoii, (New Hampshire) 23 Atl. Eep. 362. ** Mrh'i)i vs. Melvin, 58 N. H. Rep. 569 ; Grant vs. Grant, (Minnesota) 54 Xortliwest. Eep. 1059. 522 ^ SYSTEM OF LEGAL MEDICIXE. Divorces on Account of Loathsome Disease. — lu some States it is a gi'ound of divorce if either party "0"as affected at the time of maiTiage ■with a loathsome and ineui'able disease (such as lei^rosv or s^-philis), aud failed to inform the other party of this fact* If the knowledge of the disease, when gained, brought such mental anguish as to endanger health or create a reasonable apjDrehension of such danger, the act of concealment may be considered as such - cruel and alnisive treatment " as to justify a divorce, under a statute embracing that as a sufficient cause.! Divorces for Adultery. — To constitute adulteiy there must be a "Wrongful intent. If the woman is violated by force, or submits to sexual intercourse while insane, or with one whom she supposes to be her hus- band, there is no gi'ound for a divorcer It is, however, held in some States that insanity is no answer to a libel for adulter}^, and that the consequences of the act are to be regarded, rather than the guilty pur- pose of the wife.§ In no State would m-mphomania be any excuse. Proof that the husl:)and has the venereal disease, and that it fii'st be- came apparent some time after marriage, does not show that it was not conti'aeted before the marriage, and is therefore not sufficient proof of the commission of adulteiy. Divorces for Habitual Drunkenness. — Proof of ocasional intoxica- tion does not suffice to show habitual drunkenness. Indulgence in the use of chloroform, or of moii^hine by hypodermic injections or other- wise, though habitual and carried to excess, is not drunkenness. Intoxi- cation by the immoderate and habitual use of '"intoxicating liquors'' as a beverage must be estaldished.;! Divorces for Desertion. — The refusal of a wife to permit sexual in- tercourse, though uni"easonably continued for a consiclerable period of years, does not constitute deseition of her husband, so long as she re- mains a member of his household and under his roof.'] Divorces where One Party is Insane. — A petition for a divorce may be brought by an insane husband or wife, suing by a guardian or a committee appointed by a proper court :** and against an insane hus- band or wife, for an offense committed while sane, or for insanity exist- ing at the date of the man-iage. Such a petition is not supported by proof of the existence of temporary paroxysms of insanity before mar- riage, of which the petitioner had no knowledge, even though after mar- riage permanent insanity ensued.ff Divorces by Consent. — Any ordinaiy contract, as it is made by the mutual consent of the parties to it, can be also rescinded by their mutual consent. Marriage being, as ali-eady stated, something more than a contract, is not thus dissoluble. On the contrary, courts look with suspicion on any divorce proceeding, though good cause be shown, where there is gi-ound for belicA-ing that both parties are willing that * See Maynard vs. HiU, 125 TJ. S. Rep. 205. t Leach vs. Leach, (Maine) 8 Atl. Rep. 349. t Schouler on HvKhniul and Wife. ^ 504. ^ Machin vs. Machiii, 6 BaiT's Peun. Rep. 332. II Yotnu/s vs. Yotiwjs, 130 111. Rep. 230 ; 22 Northeast. Rep. 806. 51 Soutliurick vs. Sonthirick, 97 Mass. Rep. 327. ** Cotran vs. Conan, 139 Mass. Rep. 377. tt Hamaker vs. Hamakcr, 18 111. Rep. 137; 65 Am. Dec. 705. MAnniAGE AND DIVORCE. 523 tlie petition should be granted ; and if such willingness amounts to col- lusion, a divorce will usually l)e refused.* Recrimination as a Defense. — A petition grounded on adultery may- be defeated l)y proof of adultery on the part of the petitioner. Denial l)y the wife of sexual intercourse, tliough long continued and without justification, is not a defense to a j)etition by her for a divorce on the ground of adult(:'ry. It has been held no defense to her petition grounded on desertion, and, on the other hand, desertion by the wife has been held a sufficient answer to her petition grounded on adultery.t Extreme cruelty, if a statutory ground of divorce, may l)e shown, in most States, to defeat a petition In'ought for the cause of adultery .| Condonation as a Defense. — If either party to the marriage has a cause of divorce arising from the misconduct of the other, it can be w^aived or condoned by forgiveness. Occupying the same sleeping-apai-t- ment with the offender, after knowledge of the offense, is a sufficient condonation to bar the divorce.§ Occupying the same house affords a presumption of full marital cohabitation, but one that can be explained by evidence to the contrary. Condonation is less readily presumed on the part of the ^\\te, since she is the weaker party, and in a position of greater dependence. Testimony in Divorce Suits. — The rules of evidence in ordinary cases do not permit husband and wife to testify against each other. This doctrine is founded on public policy, to promote the peace of the household and support the institution of marriage. || But in divorce j)roceedings, or in case of resort to the courts by one for protection against the violence of the other, each party, from the necessity of the case, is admissible as a witness.^] The results of any physical examination made by experts must, in this country, be given by the examiners, testifying as witnesses under oath. We have not adopted the English practice of accepting a certifi- cate of the result from official inspectors. * Danforth vs. Danforih, 105 111. Kep. 603. + Schouler ou Hushand and Wife, ^ 536. X Church vs. Church, 16 Ehode Island Eep. 667; 19 Atl. Eep. 244. § Rogers vs. Rogers, 122 Mass. Rep. 423. II Lvcas vs. Brooks, 18 Wallace's U. S. Rep. 436. i[ 2 Bishoi^ ou Marriage and Divorce, $ 287. SEXUAL CRIMES. BY CHARLES GILBERT CHADDOCK, M.D. RAPE. Legal Considerations. — Rape constitutes an offense in common law, but its legal definition varies in the statutes and codes of various States, particularly with respect to the bearing- of the age of consent ujjon the crime. Rape is carnal knowledge of a woman by a man, unlawfully and by means of force, against the will and without the consent of the woman. On the jjoints of ''will" and "consent" there have been decis- ions in Arkansas, Florida, Micliigan, Nevada, and Wisconsin. Thus rape may be committed when, in sensii stricfiori, the woman shows no will at all ; as when she is narcotized, or in a state of non compos mentis. Carnal knowledge may also be rape where it takes place with consent that has been obtained through fear or fraud. Absence of consent is interpreted as equivalent to being against the will of the woman, in later EngHsh law. Rape is possible only in case of physical capacity in the direct male perpetrator; but impotence is no defense for intent to commit rape where it cannot be shown tliat the pei-petrator was aware of his sexual inca- pacity. The age of the male, in its effect upon capacity to commit rape, may be of importance in determining the conditions constituting the crime. A male under the age of fourteen cannot commit rape, accord- ing to English law ; but in the United States a few courts have held that there is no conclusiv^e presumption of incapacity determined by age.* The crime of rape may be perpetrated upon the person of any female, no matter what her age, character, or capacity. Since the question of consent is of prinuiry importance in its l)earing upon the crime, the age of the female, as affecting her legal capacity to give consent to sexual intercourse, is of the greatest importance. In common law, a child that has not attained the age of ten years is pre- sumed to be incapable of giving consent. Therefore, in geni'ral, carnal knowledge of such a child is felony. But statutes in England and in many of the United States make carnal knowledge of a child between the ages of ten and twelve a misdenu^anor. If, under such circumstances, the cliiUl consents, the offense is a misdemennor, not an assault. The age of <'onsent in a majority of the States is foui-teeu years. A New York statute nuikes it rape for a man to have sexual intercourse with a fen^de to whom he is not married who is under the age of sixteen. It is felony * New York, Ohio, Tennessee, Kentucky. 526 ^ SYSTEM OF LEGAL MEDICINE. for a man to liave carnal knowledge of a child who is under the age of ten, in Arkansas, Michigan, Mississippi, North Carolina, Wisconsin, and Texas. Intercourse with a child under the age of twelve years is rape under tlM Code of Louisiana. The age of consent is fixed at fifteen years in Nebraska ; at thirteen in Iowa ; at sixteen in Pennsylvania ; at eighteen in Wyoming and Kansas. In Ohio, decisions have been less stringent; the knowledge of the child has been taken into consider- ation. Actual carnal knowledge must be shown by direct or indirect evi- dence, in order to establish the crime of rape. Penetration, in the least extent, of the female genitals by the male organ, constitutes carnal knowl- edge. Force, actual or its equivalent, is necessary to the commission of rape ; and the force must have been sufficient to accomplish the purpose. Submission obtained by means of fear or terror induced by threats or otherwise, is construed as the result of moral force equivalent to a com- pelling degree of physical force. In law, intercourse accomplished by means of fraud, where there was no intent to use violence, is not rape. Within the age of consent, where consent is given, no matter how re- luctantly, there can be no rape. The female must have offered all pos- sible resistance, or resistance must have been made impossible by terror or other means. Commonly, connection with a woman while she is un- conscious, as during sleep or insensibility occasioned by alcohol or other narcotics, is rape ; and the same is true in cases of idiocy and imbecility,, though in New York this is merely a crime against the person. The prosecutrix in a trial for rape is a competent witness ; but in case the defendant denies guilt, her testimony must be corroborated as to material facts, though the fact of the rape need not be proved by other witnesses. The foregoing paragraph shows that there will be many cases of the crime of rape in which no technical medical testimony will be required ; but -frequently medical evidence will be called for — not in any sense tO' define legally an act of sexual congress, but to assist in the determina- tion of the question whether sexual contact has taken place or not. The physician may be required to give evidence concerning facts which indi- cate whether coitus has taken place or not ; or he may be asked to give testimony concerning any evidences of physical force used in the accom- plishment of sexual intercourse. Conditions that Indicate that Coitus has Taken Place. — Physio- logically, coitus consists of immissio penis and eniissio seminis ; but the latter is not essential to the crime of rape. Moreover, immissio penis need not have been complete, the slightest penetration of the female genitals by the male organ being sufficient in the legal sense. For the purposes of diagnosis, attention must, of course, be directed to the female ; for examination of the male can reveal nothing, save in those cases where the demonstration in him of venereal disease or of marks on his person indicative of resistance offered by the female is of importance. Examination of the female will have for its object the determination of the existence of anatomical conditions or changes affecting her geni- tals that indicate whether coitus has taken place or not; whether there are evidences of the ejaculation of semen in or about her genitals and clothing; wliether her person presents signs of violence; and whether there is any existing venereal disease or evidence of its previous existence. SEXUAL CRIMES. 527 The Anatomical Changes of the Female Genitals Induced by the First Act of Coitus. — In females that have had coitus many times, and in those that have home ehildren, the changes that have taken place in the form and condilion of the genitals are necessarily of such a nature that a single act of normal coition would leave no immediate anatomi(!al evidence of its occurrence. The repetition of tlie act of sexiud inti^-- course, and, much more, the occurrence of lal)or, enlarge the genital passage and render its tissues yielding, so that the single act of coitus takes^place without leaving a change in the parts. Still, even under these circumstances, the act may be done with such brutality as to leave marks in the form of abrasions and lacerations. In the vast majority of instances of rape, however, the crime is committed on virgins ; and often in such cases the questions the physician may be called upon to answer are : (1) Is the alleged victim a virgin? (2) Do the genitals present evi- dence of recent or remote defloration'? In a virgin, as a rule, the labia majora are firm, large, and well- rounded, theii- edges lying in intimate contact in the median line, and completely covering the labia minora ; the labia -aninora present a bright red color ; the vestibule is narrow ; the hymen is intact ; the vagina is narrow, and presents prominent folds of its Avails. While the state of the Jahia majora mentioned usually accompanies virginity, it is not a sign of much determinate value. The size and posi- tion of the labia with relation to each other depend in great nieasure upon the character and amount of subcutaneous adipose tissue in the parts. In healthy vii-gius there is usually an abundance of subcutaneous fat, and in consequence, the labia are full, well-rounded, and in close contact. Even in such instances, however, the labia readUy separate with separa- tion of the thighs, and this must be remembered in any conclusions drawn from examinadon of the labia. Anything that leads to deficiency of sub- cutaneous adipose tissue may alter the relations of the labia and cause them to separate more or less completely. In thin subjects, whether chUdi-en or virgins, the examiner must expect to find more or less defi- ciency of median contact of the labia ; but, on the other hand, if a female is well-nourished and youthful, the labia may stiU be in close contact, even though coitus has been performed many times. Again, as age ad- vances the subcutaneous areolar tissue loses that firmness characteristic of youth, and in consequence, though w^ell-nourished and a virgin, a fe- male beyond the years of youth may show marked separation of the labia. From these facts"^ it will be seen that the conditions and relations of the labia depend more upon the general condition of health and age than upon whether coitus has taken place or not. The condition of the lahia minora depends largely upon the condition of the labia majora. As long as the nymplia? are covered by the latter, the membrane covering them retains its original characteristics ; it is moist, and presents a rosy tint. After alteration of the position of the Libia majora induces constant exposure of the nympha% the mucous meni- brane covering them undergoes changes wliieh cause it to resemble epi- dermis. It is" less moist, and the rosy hue changes to a distinct brown. This dependence of the condition of tlie labia minora upon the condition of the labia majora allows no absolute value to attach to the condition of the nymphjTp in determining the question of virginity. The condition of the lu/iuen is of much greater value as evidence of 528 ^ SYSTEM OF LEGAL MEDICIXE. "^ ATi'ginity or defloration. But even the state of this membrane will not always save from an eiToneons conclusion. The hymen is not always ruptui-ed in the first coitus ; it has been found intact even after labor. Moreover, the hymen may be altered by other means than the penetra- • tion of the male organ. The hj-men frequently presents anomalies and defects, as well as variations of form of slighter degree ; and an understanding of these possibihties is of great importance for a correct appreciation of the changes in the hjTuen induced by coitus. The hjTuen is commonly regarded as merely a fold of mucous mem- brane closing, more or less perfectly, the entrance of the vagina ; but Pozzi * has shown it to be a structui-e of much more definite morphology. The hymen makes its appearance somewhat late in fetal life, for it can- not be distingiiished until after the fourth month, when the differentia- tion of the genital organs has become quite complete. At fu-st it is seen as two folds which apx)ear, one on each side, at the opening of the uro- genital sinus. Advancing in development, these two folds meet and fuse in the median Hue, lea^'ing at the vaginal orifice the hsineneal opening. The primitive folds of the hymen extend forward fi'om the ostium vaginae to the base of the clitoris, forming a cii'cular fold about the orifice of the nrethi-a, and uniting in the median line of the vestibule to form the frenum masculinum. Thus, morphologically, the hymen is the repre- sentative of the male corpus spongiosum, and it is to be regarded as an organ modified by arrest of develoj)ment. In the infant the hymeneal folds are well developed and prominent, but the vestibule hes deeply between the labia. It is pointed out by Pozzi t that when the hymen has the labiated form (two lateral folds), in the iufant it might be mistaken for the nymphae, owing to the considerable size of the folds at an early period of life, and lead the observer to conclude that the hymen is absent or destroyed. The possible medico-legal im- portance of such an error is apparent. In children at bii'th, owing to the depth of the vestibule, the hymen is more deeply placed than later in life. However, this infantile peculiarity may jjersist in youth and be found even in adult life. Tm-nipseedt states that in the negro race this peeuharity is very marked. Such a deep situation of the Inmien, espe- cially in adults, might lead to the erroneous conclusion that it is absent. Congenital absence of the hjonen is certainly very rare. Modern observers are in accord in stating that they have never met with an in- stance of it. The cases of it reported by older "winters are probably ex- amples of en'oneous conclusions due to a want of knowledge of the I)ossible variations in form and situation to which the hymen is now known to be subject. In stracture the hymen is usually thin and membraniform. It is made up of the folds previously mentioned, which lie in apposition. These lateral folds may remain perfectly distinct ; but usually they are fused together more or less perfectly, commonly leaving a single opening into the entrance of the vagina. In some cases, however, there are marked deviations from the ordinary structui-al characteristics. The * S. Pozzi: "De la Bride Masc," etc., BulL et Mem. Soc. Biolog., Januaiy 26 and Febniary 16, 1884. * Gi/)iecolof/!/, vol. ii., p. 44.3. X Am. Jour, of Ohstet., 1877, vol. x. SEXUAL CRIMES. 529 hymen may be found tliiek and fleshy; or it may be so dense and inelas- tic as to present an obstacle to normal coitus which the male organ can- not overcome. On the other hand, the liymen may be so elastic and yielding" as to survive uninjured the strain of coitus, or even that of labor. However, instances of the latter kind must l)e exceedingly rare. Tlie condition of an uninjured hymen might be of some value in de- termining the question of coitus. A dense, unyielding liymen would positively exclude complete penetration, providing its opening were suffi- ciently small to prevent iniDiissio penis. On the contrary, an uninjured hymen of exceptional elasticity would not prove that the act of coition had not been ])erformed. It should also be renuMul)ered that it is pos- sible to dilate the hj^neneal orifice gradually without gross injiuy to its tissues. By this means ruptiu-e of the hymen is avoided in the gyneco- logical treatment of virgins. Exceptionally, the hymen is exceedingly vascular, and in such cases its rupture may be attended ^xiih. alarming and even fatal hemorrhage. Cases of multiple hpnen have been re- ported ; but all such instances are to be explained as the residts of path- ological adhesion of the vaginal walls. Such adhesions usually occur early in life, if at all, and they may persist up to adult age. Since the hymen is developed from two lateral lamintp, as might be expected, in childhood it is usually found in the labiated form. Gradu- ally these original laminaj be- come fused in various ways, lead- ing to a great variety of forms of the fully-developed hymen. In the adult the hymen is most com- monly anmiJar in form (Fig. 69) ; but this tjTpe has received vari- ous names in accordance with the variations of form produced by variations of the position of the hymeneal oriiice. Infrequentl}^ the opening is found occupying a central position in the mem- brane. More commonly the ori- fice lies in the anterior haK of the mend)rane. The shape of the hymen varies also in accordance with the size and form of the opening. The hymeneal aper- ture nuiy be circular, but more commonly it is oval, with its long diameter l.ying antero-pos- terioi-ly. The diameter of the opening varies widely. It may be so nar- row, both in childn^i and adults, as merely to allow the passage of an ordinary soimd (10 mm.); or it iwaj be so large that the hymen forms scarcely any obstruction at the entrance of the Aagina. Inqteyforate Jiijnien, while occasionally observed, is certainly a rare condition ; more commoidy the atresia of the vagiiui, presumed to be due to imperforate hymen, is due to an imperforate ct)ndition of the vaginal canal itself. Under such circumstances, the hymen is fouiul in close contact with the imperforate membrane derived from the fusion of the vaginal walls, the Fig. (lit.— Annular hymen. (After Hofmann.) 530 A SYSTJSM OF LEGAL MEDICINE. hjonen presenting its normal perforation. When the hymeneal opening is comparatively large, and anteriorly situated, the hjanen has the cres- centic form (also called falciform). (Figs. 70 and 71.) A crescentic hymen with the orifice lying posteriorly, and the membrane anteriorly, is nn- Fig. 70.— Crescentic hymen. (Roze.) Fig. 71. — Crescentic hymen, horseshoe. (Roze.) known. When the opening is long and narrow, running antero-poste- riorly, the membrane is practically made up of two symmetrical lateral halves, and the hymen is then said to be lahiated — a persistence of the common infantile form. Fig. 73. -Hymen fimhriatus, intact. Hofmann.) (After Fig. 73.- -Ruptured hymen fimhriatus. (After Hofmann. ) The free edge of the hymen bounding its orifice is subject to much variation in form, and this occasions a variety of forms of hymens. In many cases, when the membrane is made tense, its free margin may be traced as an unbroken line, forming a ring or semicircle, as the case may be. Aside from variation in general outline, however, the free edge SEXUAL CHIMES. 531 may present various irregularities. It is frequently found notched. These indentations of the free margin may l)e situated anteriorly or posterioi'ly, l)ut their most eommon seat is in the anterior part of the membrane. Usually the meml)rane is notched symmetrically on each side. The notches vary in depth, from a slight irregularity of the edge of the memhrane to division of the membrane down to the vaginal wall. Thus two deep notches symmetrically placed, one on each side, may divide the hynuMi into four parts. There may be an anterior and a posterior notch on each side. These natural irregularities of the free margin of tlie liyiiien, when present, are of some medico-legal iinportau(;e. Careless observation might mistake them for artificial tears that had healed. Close examination of such natiu-al not(;hes will show the absence of cicatri- cial tissue and the integrity of the mucous meml)rane covering them. In rare instances the free edge of the hymen presents a large luimber of shal- low notches ; and still more rarely it may be fringed {hynioi finihviatns, Figs. 72 and 73). The hymeneal orifice nuiy be found divided b}- a narrow l)aud of membrane [lupnen S(Lptus). The meml)ranous septum di^•iding the orifice usually extends autero- posteriorly, either in the median line or somewhat ol:)liquely. The two hymeneal openings, under such circum- stances, may be approximately equal, or very unequal, in size ; commonly they are manifestly unequal. (Fig. 74.) The hjaneu sa?ptus has been looked upon as a proof of the origin of the hymen in the Mlillerian structures ; but, as previously shown, other considerations must cause the abandonment of mg^m^^^%.t\ fm ^^i^--' i:^ 1>V! ^. X Fig. 74.— Hymen sa-pi iis. \\\\\\ unequal open- ings. (Alter llofiuaun.) Fig. 7.5.- -Hymen with posterior rudimentary, septum. (After Hofmann.) this view. In some instances but one lateral hymeneal orifice is fotmd, the other having become closed. In other instances the septum is found at- tached to the edge of the hymen only at one point, so that it forms a long, slender process. (Fig. 75.) In very rare cases the hynuui presents a large number of small perforations, constituting the variety called (■riJ»-ifon)i. In the normal, itnstrained position of the genitals, the hymen does not present at the opening of the vagina as a tense membrane ; rather it 532 A SYSTEM OF LEGAL MEDICINE. is seen folded on itself. The manner in wliicli tlie lijanen is folded, nnder such circumstances, varies somewhat in accordance with its form. The crescentic hymen presents a median antero-posterior fold, resem- bling a raphe ; the edge of the circular hymen is folded in such a way as to form the wrinkled aj)ex of a cone directed externally. With wide separation of the thighs and labia, these conditions are altered ; the mem- brane becomes more or less tense. This is more especially true in adults ; in children separation of the thighs and labia does not so readily affect the state of the hymen, because, in early years, it is of greater area than the introitus vaginae. The presence of an uninjiu-ed and intact hymen is in itself strong presumptive proof that the normal and complete act of coitus has never taken place. Such a hjanen does not, however, exclude, in any case, the possibility that partial penetration, as into the recess between the labia and into the vestibule, has taken place. Furthermore, notwithstanding the intact condition of the hymen, its physical peculiarities are of importance, as has been previously mentioned. An uninjured hymen might exhibit such a marked degree of elasticity as to raise the question of its possible distention without rupture in the act of coitus. Again, the size of the hymeneal orifice might have some bearing upon this point : an opening unusually large would require less elasticity in the narrow membrane to permit penetration by the male organ without rupture ; an opening of small diameter would speak against the possibility of complete penetra- tion without rupture, notwithstanding marked elasticity of the hymen. Of coiu'se, in all questions on these points the size of the male organ must be considered. Fig. 76.— Ruptured crescentic bymen, with two Fig. 77. lateral lascerations. (After Hofrnann.) -Circular hymen, torn in several places. (After Hofrnann.) As a rule the hymen is torn more or less in the first act of coitus. The resulting lacerations of the membrane vary in character, in part owing to the variations in its form and structural character. Usually ^EXi'JL CIUMJ-JS. 533 i^7^"c:^i-^ sui'li lacerations start from the free margin of the hymen and extend through the memhrniie to its jnnetion with the vaginal tissn(\s. Usually the labiated hymen is found torn posteriorly in the median line, the tear dividing' the hymen into two perfectly distiuct lateral valves. The cres- centic hymen commonly tears on each side in snch a way as to leave an approximately triangular median valve attached along the posterior edge of the vaginal entrance. (Fig*. 70.) The circnlar or annular hymen tears in four or more places, dividing- the hymen into several valvidar remnants, (Fig.77.) Th(^ structure (»f the hymen may determine departures from these rules. Relative weakness of one part may inllnen(;e the direction and extent of the laceration. The hymen sa'ptus is peculiar in this respect, that laceration of hnt one side may take place, the sep- tnm and opposite side remaining intact. In recent cases it cannot be difficult to recognize that rup- ture of the hymen has taken place. There Avill he the his- tor}' of hemorrhage, and perhaps the evidences of it. The mem- brane will present the unhealed edges of the lacerations ; and the r(Mnaiuing tissue of the hjanen will prol>ably show some degree of inflammatory hypertemia and swelling. As a rule hemorrhage is insigniflcant where the lacera- tion is confined to the hymen itself, but it may be, as ali-eady mentioned, so considerable as to call for surgical interference. Profuse hemorrhage following a first coitus, or, more especially, an at- tempt at rape, is usually due to laceration of other parts than the hymen, either du-ectly or by. extension of the laceration of the hymen into the vaginal wall. Repair of the ordinary lacerations of the hymen takes place in two or three days, but the sevei-er and more extensive tears may require a con- siderable period to complete healing. The presence of inflannnatory red- ness and swelling and exudation about the edges of the w. 137. 538 -i systjEM of legal medicine. to mistake this for gouorrliea. For gonorrhea may not be found in the- alleged ravisher, and thus a false ground for defense might be established. Among the more common causes of muco-purulent genital discharges in females are disordered menstruation ; masturbation, however prac- ticed ; skin diseases ; oxyiuis vermicularis, alone or in conjunction with manual irritation. Genital catarrh may also be an accompaniment of a general enfeebled state of the organism, as in tuberculosis and chlorosis. Vulvo-vaginal catarrh sometimes occurs in an epidemic form. The pos- sibility of diphtheritic uiilammation of the genital mucous membrane is also to be remembered. The close resemblance of venereal inflammation to simple inflamma- tion of the genital mucous membrane has led designing mothers to excite the latter in their young daughters, by mechanical means, for the j)urpose of blackmail or revenge. In a given case it may become essential to determine the relation be- tween the alleged tune of infection with s]3eciiic venereal disease and the stage of the malady indicated by conditions found upon examination. It is necessary, therefore, to consider the periods of incubation more or less characteristic of such affections. Great care must be exercised in gi\iug medico-legal opinions concerning ulcerative processes affecting the female genitals. The differentiation of such j)rocesses from sj^phUitic sores does not present much difficulty ; but errors maybe made if it is not remem- bered that ulcers of other kinds may simulate the hard chancre, owing to some induration of their bases ; that syphilitic induration is not always tj^Dical. The diagnosis is not to be made until after thorough considera- tion of all the e\ddence. The diagnosis of soft chancre is to be made more especially from its coiu'se than from its character and seat. To be sure, soft chancre can be diagnosticated by inoculation on the person affected, but such a means will rarely be expedient. It may be necessary to distin- guish soft chancre from herpes. Ulcerative and gangrenous processes of various kinds affecting the genitals may be mistaken for venereal affec- tions ; more especially noma and diphtheritic ulceration, which sometimes affect the genitals of female children after scarlet fever, t^^phoid fever, and measles. For the expression of a medico-legal oiDinion in cases where the question of venereal disease is a matter for decision, it will be seen that a thorough acquaintance Avith all the characteristics of the venereal affections is essential ; however, such knowledge is to be gained best in works devoted speciall}^ to them, and it does not fall properly within the scope of this article to enumerate diagnostic criteria. In any case where the existence of venereal disease is accessory evi- dence of rape, examination of the person of the accused will give addi- tional evidence of gi-eat importance. It is impossible to do this, how- ever, mthout the consent of the accused. The presence of similar disease in the j^erson accused becomes strong cii'cumstantial eAddence against him. It is to be remembered how chronic gonorrhea in the male may easil}^ escape observation, and precautions are to be taken to guard against such an error. The urethra is- to l^e examined some hours after the last act of urination. A gleet, while on the whole less infectious than a gonorrhea in its active stage, may infect, and that the more readily in case of genital contact with virgins and children. On the- other hand, the existence of disease in the female and its absence in the male accused is evidence of his innocence and of her leM'dness. StOl,. SEXUAL CRIMES. ;j;J9 there may be sexual eoutaet iinder such ch'cumstances without infection. However, a diseased i)rostitute accusing a man of rape would with diffi- culty sustain her charge in case the accused were free from infection. Again, the absence of disease in the accusing female and its presence in the accused male would (n)nstitute strong evidence that sexual contact had not taken place, espcicially were the female a virgin or a child, and the disease gonorrhea; at the same time, these conditions would \n)X, actually disi)i'<)ve sexu.-d contact. The Physical Evidences of Force. — ►Since there can be no rape where there has been no force, actual or constructive, it may become the duty of the medical witness in a trial for ra})e to give testimony concern- ing tangible evidence of the use of physical force. Severe injiuies, such as might result from blows, choking, l)rutal violence to the genitals, etc.^, do not })resent any difficulties; where injuries are slighter, the questiou of their self-inttiction l)y the alleged victim must be considered. Signs of force may speak as well for the degree of resistance of the victim. The old (piestion whether it is possible for a single man to force a woman of good physical development, while in full possession of her senses, tO' submit to coitus, is quite beside the mark in cases of actual rape. Un- der such circumstances, though a woman might appear to be physically capable of successfully resisting the sexual ap^rroacli of a man, her failiu'e to do so would be no evidence that she had not offered all the resistance possible for her at the time. Even though the man were proportionately weaker than the woman the same would hold true; for the psychical excitement induced in the woman by the attack might l)e suificient to nudce her physical resistance less effectual than it would otherw^ise be. When a woman is attacked by a man with intent to compel her sub- mission to coitus, no matter what her physical strength, the initial ener- getic resistance she .offers will probaljly grow less under the influence of pain inflicted by the ravisher in his efforts, and as a residt of the wom- an's psychical 'excitement and fear that the greatest bodily hai-m may be inflicted. "Aie wonuin's mental condition may, through apprehension, finally become such as to make physical resistance no longer possible. However, remembering the frequency with which false charges of rape are made, it may become necessary to consider the comparative strength of acicused and accuser. In case it seems that the woman were capable of offering effectual physical resistance, it is proper to direct attention to the discovery of conditions that may have prevented its exercise. Where strenuous resistance has been offered by a woman, physical evidences of the force used by the man will rarely ])e wanting; always provided that they are souglit before sufficient time has elapsed to allow their renu)val by natural processes. The physical evidences of force will be the more obvious the more strenuous and long-continued resistance has been. Scratches, bruises, and more serious injuries on the person of the woman nuiy lie in evidence. These injuries may be found on almost any part of the body, but they are most frequently seated on the limbs, es])ecially the thighs. The external genitals often present evidence of violent treatment. Some caution is necessary in determining the nature of marks pre- sumed to be the evidence of the infliction of violence. Natural pigmen- tations of the skin have been mistaken for suggillations. Self-inflicted marks and injuries are usually slight, and to be found only on parts of 540 ^ SYSTEM OF LEGAL MEDICINE. tlie person easily reaclied by the hands. The genitals are usnally the parts chosen for injury by a woman seeking to deceive. In any case, injuries presented as evidence of force used in the aecompHshment of rape are to be considered with resj)ect to the relations their aspect at the time of examination bears to the time they are asserted to have been inflicted. The person of the accused may also give evidence of a physi- cal kind of the resistance offered by the victim. Scratches, bruises, and wounds made by biting, may be found. Injui'ies of the male genitals are not unusual. Moral Force. — ^When coitus is accom]3lished by means of threats of violence, the resistance of the female being thus precluded by fear, the act is none the less rape ; but under such circumstances the e^ddence that resistance was thus obviated requires no medical interpretation. The threats used may be directed against the woman's own .person or against others. Thus, a mother might be forced to submit to coitus by threats dii-ected against her chrLdi-en. Resistance to sexual attack may be prechided by 23hysical or mental conditions. A female in an invalid condition might be incapable of offering any physical resistance. Fraud. — In law, intercourse accomphshed through fraud, without intention to use violence, is not rape ; but unlawful connection with a woman while she is asleep, unconscious, or insensible as a result of in- toxication by alcohol or other narcotics, is commonly rape. Where co- itus is accomphshed upon a woman by a man who takes advantage of circumstances — darkness, etc. — to have himself mistaken by her for her husband, the act is one of fraud ; and if there were no intention on the part of the man to use violence, such a crime coidd not be legally held to be rape. At the same time, a sense of strict justice could but regard such a crime as much a rape as coitus performed with a female whose senses have been befogged by intoxicants. Again, for example, coitus performed by a j^hysician with a patient on the pretext that the act is a necessary part of medical treatment is not rape, but fraud ; though it is possible that such a crime could be made rape in law by pro\dng the imbecHitj' of the victim ; or her want of adequate knowledge of the nature of the act, if such could be shown, shoidd establish the same de- gree of ii-responsibility for consent that obtains in cases of children. States of Unconsciousness. — It has been a mooted question whether coitus could be performed on a female sleeping normally without awak- ening her. That such a thing is possible must be admitted; but there woidd needs be a rare coml>ination of circumstances to make the possi- bihty an actuality. A married female might be subjected to the sexual act without rousing from slumber; but a female who had never per- formed coitus would certainly be awakened from any normal sleep by the unusual manipulations and pain necessarily attendant upon the act. Sleep and a favoring position, vnth absence of impeding garments, might make the commission of rape easier, and permit the perpetrator to gain such advantage that the female, on awaking, would find all her resistive efforts f utde. States of unconsciousness differing from that of normal sleep, in that they are deeper and less easily overcome, may be used as aids in the performance of unlawfid coitus. Such unconscious conditions may be purposely induced for an ultimate sexual object ; or being present, they may be utiUzed for such a purpose. A woman might be purposely in- SEXUAL CRIMES. 541 dueed to take alcohol to intoxication, and lier condition utilized for a sexual purpose. If, while intoxicated in this way, a woman still offered resistance to the sexual ai)proacli, or if she were so far unconscious as to know or remember nothin<>- of the act, the crime woidd be rajjc. How- ever, if under such cu'cumstances a woman were to give consent, the criminal sexual act would not be rape, notwithstanding the contributing effect of the intoxi(^ant, unless unconsciousness of the acquiescence could be proved. In such a case, where an adult female is concerned, it would be assumed that she wei-e more or less acquaintt'd with the effects of alcohol, and that she knowingly took that which would lower her moi'al resistive power. With a youthful fenuxle unaccpiainted with the effects of alcohol in the ordinary forms in which it is taken, the case would Ijc quite different ; and consent under such circumstances might not, or shoidd not, qualify the crime. Other narcotics might be purposely or secretly administered for the purpose of removing the possibility of resistance to sexual approaches. The most important of these are chloroform, ether, nitrous oxide, opium and its alkaloids, and cliloral hydi-ate ; but there ai'e many other sub- stances that might eventually be used to serve such a purpose. There are but veiy few cases on re(;ord in which the more powerful narcotics and ana?sthetics have been used primarily mth the purpose to induce a ■condition that would render resistance to coitus impossible; but there have been numerous instances in which the effects of these agents hav- ing been induced for other purposes, the opportunity has been used for sexual approach. This is especially true of anaesthetics administered for surgical procedures. Not infrequently the complaint is made that un- consciousness has been suddenly induced by the sudden and unexpected use of chloroform or similar agents. Such statements are to be accepted only with the greatest caution ; for such substances do not produce im- mediate unconsciousness. The question of the possibihty of chlorofornnng a sleeping person without disturbing the slumber may call for au answer. Experunenta- tion to test this pi'oblem has shown that it is possible to induce ant^s- thesia with chloroform without interrupting normal sleep ; Init to do this successfull}', knowledge of chloroform and skill in its adndnistra- tion are required ; and even with e^^ery scientific precaution the chance of failure is as good as that of success. Therefore, the probabilitit's are much against the success of an attempt by an unskilled operator to •chloroform a sleeping person without breaking the sleep. Where other narcotics are in question, an appeal to known physiological actions will •often prove valuable in determining the nature of testimony. Other states of temporary unconsciousness seldom aff'ord o])portmiity for sexual approach. Maschka records the case of an eiiileptic girl who accused a num of having had sexual intercourse with her while she was unconscious after a seizui-e ; but the details slu' gave of the events that took place during her unconsciousness were sultieient to invalidate her testinumy. Ilijpnosis might be used as a means to prevent resistance to sexual approach ; but aU cases in which accusations are made upon this basis should be scrutinized with the greatest caution. In such a case, it may not be difficult to prove that the fenude is amenaT)le or not to hypnosis, •or to detect malingering ; but it may be impossible to show that she was 542 -^ SYSTi:2I OF LEGAL MEDICINE. in an li}-[motic state at the time of tlie alleged sexnal assault. In the cases of this kind thus far reijorted, the females have been invariably hj'Sterical. Again, the h;yT^)notic state is in itself an abnormal state of consciousness, and any statements based upon perceptions of events had dm-iug such a condition should be accepted only with a full under- standing of that fact. The h^^Duotic state is one preeminently hallu- cinator}-, and therefore prone to originate false ideas, especially iu the hysterical subject. For this reason, "there can be no excuse for the in- duction of the hj-pnotic state in a female by a man mthout the presence of witnesses. Certain autohj-pnotic or cataleiDtic states that sometimes occur in hysterical females might be used for sexual pnrposes ; but here, as in states of hj^^nosis induced by a second person, testimony given by the subject should be corroborated by more objective evidence than alleged perceptions of events during such an abnormal state of consciousness. False Accusations. — Women frequently accuse physicians and den- tists of ha^-ing taken improper hl^erties with tliem while under the influence of an anEesthetic. Experience teaches that such accusations are to be taken only with the gTeatest caution. In the majority of such cases, the state- ments are the outcome of iQusions or hallucinations to which the female was subject dm*uig the period of temporary unconsciousness. Usually the_ alleged victim asserts that unconsciousness was incomplete ; that while robbed of all power to make any resistance, there was still con- sciousness of aU that was taking place. T\Tiere testimony of this char- acter is offered, it should never be given weight mthout other independent evidence ; for it is testimony coneerniug events confessedly experienced or observed during an abnormal state of consciousness. This consider- ation alone should be sufficient to exclude it as trustworthy testimony. The best proof of the justification of this position with regard to such testimony is offered by the numerous cases in which such a,ccusations have been made in the face of the contrary testimony of other persons who were present at the time of the alleged sexual assault— even of the parents of the accusing female. In the face of the frequency with which such accusations are made, no cii-cumstances can justify the administration of an anaesthetic to a female by a physician ^^dthout the presence of others. Accusations of a sexual natm-e against physicians and others are frequently made as a result of more obvious mental anomahes in the accusers ; Ixit in such cases, the very nature of the accusations, with other evidences of mental disturbance, are usually sufficient to establish their_ true character. Designing females have taken advantage of the physician for pui-poses of blackmail, by lodging accusations of improper relations at times of consultation in the absence of mtnesses. The fre- quent necessity for unwitnessed couference between physician and patient affords excellent opportunity for a designing woman. " The possibility of troiiljle of this kind is so great that the physician jealous of his repu- tation cannot afford to take risks, more especially in the practice of gynecology ; it is his duty to himself, as to his patient, to have a female witness at hand in aU cases of genital examination, etc. False accusations founded upon genital disease in children, and upon such disease induced for the purpose of blackmail, have been abeady alluded to in preceding pages. SEXUAL CHIMES. 543 states of Non Compos Mentis. — Unlawful intercourse with a female idiot or imbecile, or with an insane female, is commonly rape. In such a case resistance and force may have been in play, as in any other ; but, under such circumstances, ordinaril}' the question of the crime of rape hangs upon tlie irresponsibility of the female for the assent she may have accorded. The proof of the mental condition of the prosecutrix then becomes indispensable ; and this must follow on general psychi- atrical lines. At the same time, in case consent has been given by an irresponsiljle female, it would also be oljligatory on the part of the prosecmtion to show that the accused was aware of the irresponsibility of the female, in order to bring the crime within the legal definition of rape. Actual and Apparent Age. — Sexual intercourse with a female under the age of consent is, under all circumstances, rape. It would seem, liow- ever, that where the age of consent is high (fourteen years) there might be conditions which would mitigate the crime. Though under the age of consent, a girl might be so fully developed as to make her appear much older ; and her consent to a sexual approach, or invitation of one, should then, in the ignorance of the man, be given the weight of the consent of one of the age which she appears. Such a case is considered by the Austrian law. Sexual Assault of Children. — Rape of children is the most frequent form of sexual crime. The majority of children thus abused are of tender years ; even babyhood is not exempt. The age in recorded cases ranges from eight months upward. There are no statistics shomng the num- ber of cases of rape and the proportion of children concerned in America, but statistics show that in France from 1851 to 1875 inclusive there were 22,017 cases of rape brought to trial. Of this uumber, but -loGO con- cerned adult females ; the remainder, children. (Tardieu.) Of 406 cases of alleged rape examined by Casper and Liman, 84 percent, of the females were under the age of fourteen, and 70 percent, below the age of twelve ; and in 248 cases reported by Maschka, the age was below fourteen in 171 instances. It is but natural to seek soem reason for the great j)reponderance of such sexual assaults of children. The superstitious ignorance which fosters a belief that gonorrhea is cured by intercourse with a vii'gin or child would have an influence to increase sexual assaults on children where it prevailed. Many times children are approached because they can be persuaded more readily than others to sulmiit to embraces of the nature of which they ai'e ignorant ; or because, if need be, their i-esi st- ance can be easily overcome. Similarly, old women may become victims by reason of their presumed lack of power to offer physical resistance. In some instances children fall victims to men who have not the courage (fear of impotence) to attempt intercourse with adult females. Througli fear of possible failure with an adidt, and consequent ridicule, a young man may first essay sexual contact with a child. Intercourse may be attempted mth a child with the thought to seek a new stimulus to sexual power exhausted in sexual debauchery with women. Sexual assaults upon children by aged men are especially frequent. In such cases, in the male there is usually a coincidence of impotence and libido : sexual desire prompts to the sexual act ; but consciousness of inqiotence. and the impossibilit}' of gaining the consent of an adult to sexual approach, 544 J SYSTE2I OF LEGAL MEBICIXE. cause siicli old men to seek cMldi-eu, in wliose igTiorance ther would conceal theii- deiieieney. In such, men mental failui-e is an invariable accompaniment of such acts. Sexual perversion (erotic feticMsm) might lead to an unnatiu'al preference for childi*en. Finally, in a certain pro- portion of cases, children fall victims to the sexual appetite of males through the accidental coincidence of association, inordinate passion in the male, and favoring cii'cumstances. In cases of alleged rape of childi'en, consideration of the physical condition of the genitals of both parties becomes very important. The younger and more undeveloped the child, the smaller the possibility of actual penetration by the adidt male organ. As a rule, owing to the common disproportion of size, the sexual contact is confined to the w\l- var fissiu'e. Where this disproportion exists, and the forced entrance of the penis is attempted, laceration of the child's genitals is almost inevi- table, owing to the delicacy of the infantile tissues. Still, where lacera- tions of a child's genitals are found, the question arises at once whether they could have been caused by the erected male organ. Owing to the limited power of the penis to overcome resistance, where serious or exten- sive lacerations of a child's genitals are found they are to be attributed to brutal attempts to bring about dilatation by the fingers or other un- yielding object. It should be remembered tliat even a child's genital passage may be enormously dilated by j)ersistent gentle efforts, without the production of lesions ; and marked disiDroportion between the age and the size of the genital passage of a child should be given weight as e^ddence that she has been used for sexual piu-poses. * Secondary Consequences. — ^Medico-legal questions may arise con- cerning the ultimate consequences of rape to the ^-ietim. Impregnation may result, and place additional Hability on the radish er. Injuries inflicted by the rape may, aside from the effects of venereal infection, seriously affect the health of the female ; and such injmies may even cause death, as nimierous cases reported l)y Tardieu, Taylor, Casj^er, and others attest. Such eases show that death, iinder such cii'cumstances, may result earl}^ or late, in accordance with the immediate cause. Thus it may be due to shock, hemorrhage, sepsis through wounds inflicted in the immediate sexual act, and to hemorrhages into the central nervous system. Geni- tal wounds may dbectly or indirectly implicate the peritoneal cdiYxtY and lead to a fatal peritonitis. Since sepsis may play a veiy important part in these cases, it becomes of the gi-eatest importance that the physician examining such an injui'ed female exclude by the most rigid asepsis in his examination the possibility of a defense based on the assumption that he made secondaiy sepsis possible by his manipulations and in- struments. Rape of Male Children. — The Enghsh common law does not recog- nize rape of male childi-en by mature females, but such an offense is recognized by the law of some Continental nations. In the United States such crimes are punishable under the laws of some States, as indecent assaidt. The most serious consequences to such children is venereal dis- ease, aside from moral injury, and cases of this kind are not of gi-eat rarity. * Cf. Indecent Assault upon Children, vol. i., p. 649. SEXUAL CRIMES. 545 SEXUAL ABUSE OF CHILDREN * Closely related to the crime of rape, but widely separated from it in a legal sense, is sexual abuse of children. The common law docs not recognize sexual abuse of tins nature as su(^h, but such inujionil acts may Ix'come the basis of legfd proceedings, and various medi(.'o-lcg-al questions may be raised in siuih cases. Sexual al)nse, in the sense in which it is here employed, signifies sex- ual manipulations which are unrelated to the normal sexual act. Mun- nstupration nuiy l)e pra(;ticed upon the person of a male or female child by a man or woman ; or children may be induced to perform such an act on one another as an exhiljition ; or, again, they may be persuaded to manipulate the genitals of the seducer, male or female. For the most part, the cases of this kind that have the greatest medico-legal imj)ortan(;e are those in which female children are abused by men. In such cases, questions arise similar to those that are of such importance in instances of rape under like circumstances. The age of the alleged victim would be determinate. It would be essential to con- sider any evidences the female genitals might afford of the natm'c of abuse. The presence of coarse anatomical changes will depend, of course, upon the force or brutality of the manipulations to which the parts have been subjected, and as well upon the frequency \\\\\\ which they have been repeated. Merely gentle titillation woidd leave no sign behind, unless frequently repeated ; and it would be necessary to em- phasize the impossibility of distinguishing a condition of irritation induced at the hands of a second person from that due to self-abuse. At the same time, the child is apt to confi.ne her manipulations to the vestibule ; a second person of maturer years would be almost cei-tain to attempt to enter the vagina. The state of the h^anen and the hymeneal opening, as well as the capacity of the vagina, might give evidence of laceration or dilatation. Wliere gross anatomical changes of the geni- tals of a female child are found, the question of rape arises ; but it must l)e remembered that such changes are much more commonly the result of manipulations made preparatory to an attempt to introduce the penis than the result of the primary introduction of that organ. Too, injuries may be found which could not possibly have been induced by the male organ. Other forms of sexual abuse of cliildi-eu can seldom afford physical evidence of their practice in effects left in the genitals. Medico-legal questions in relation to such crimes will oftenest arise in respect to the mental condition of the perpetrators. SODOMY. In English common law, sodomy is a very broad term, covering ped- erasty, buggery, and bestiality. The common law defines sodomy as carnal knowledge committed against the common order of nature by man with man, or with wonuiu ; or by man or woman with a beast. In early times in England the offense was regarded as highly penal. Grad- ually it came to be looked upon as less heinous, until by statute it was * Loc. cit. 546 ^ SYSTEM OF LEGAL MEDICINE. again declared to be a felony in the reign of Henry VIII. This statute was repealed and again re^dved in the time of EHzabeth. Thus, by the common law of the States sodomy is an offense ; but whether it is a <3rime or a misdemeanor is uncertain. In England it was formerh^ the custom to bmm or bury the offender alive. In the reign of Richard I. it was customary- to hang a man and drown a woman proved guilty of the crime. The piuiishment now in England is penal ser\dtude for ten years or more. With sodomy, as with raj)e, it is necessary to have 23roof of penetra- tion in order to establish the fact of carnal intercom'se. The e^ddence of a prosecuting witness, if an accomplice, is not alone sufficient. The English common law takes no cognizance of the common form in which coitus is imitated by males between the thighs — coitus inter femora ; and it makes no reference to an unnatural sexual act that women indulge in — namely, Lesbian love, or tribadism. Pederasty in law is the act of immissio penis in anum. Both parties to the act, where both are voluntary participants, and both have reached the age or condition of legal responsibility, are j^unishable. As indicated "by the legal understanding of the term, pederasty may be accompUshed by male with male or female. Pederasty is both active and passive. The active part is always taken by a male ; the passive role may be enacted by a male or female. The active party may perform the act upon the person of the passive party by force and without the consent of the latter ; and under such cii'cumstances pederasty becomes similar to rape. On the other hand, the act may be permitted by the passive party, who may be legally in- capable of consent. Again, a passive party may persuade a legally irresponsible active party to the crime. However, the majorit}" of the instances of the crime are cases where there has been mutual consent of both parties, with mutual responsibility, and consent of the passive party, with legal irresponsibility. Forcible performance of the act by the active party withoiit the consent and against the will of the passive party is rare. As in rape, so in pederasty, owing to the paramount importance of physical evidence, there has been a persistent effort made to discover pathognomonic physical signs left after performance of the act. Many such signs have been described by various observers, but they are of no trustworthy diagnostic value. Thej^ call for notice here, if for no other reason than to have then* worthlessness pointed out. It is clear that the person of the active pederast could offer no unequivocal evidence that he had performed pederasty. Tardieu thought, however, that habitual indulgence in the act led to a change in the form of the glans penis, at least in some instances. In some pederasts he found the organ pointed. Such a peculiarity of form, however, could be justty attrilrated only to a develoiDmental defect. The same may be said of constriction of the body of the penis at some distance behind the glans, which might be pre- sumed to be due to pressure by the contracted sphincter ani of the pas- sive part}' to the act. Abrasions of the penis might result from its forcible introduction into the anus, but such signs could, of course, have no diagnostic value. Passive pederasty would seem capable of inducing more determinate anatomical changes in the person given to it ; but practically such pos- iSKXLAL CniMES. 547 sil)le alterjitions are of little ijositive value save in a few instances. AYliere the iiiniiissio penis in anntn lias been forced, espeeially in children, abrasions, lacerations of the mucous menil^rane, and even more extensive tears, with accompanying- signs of intiamniation, niigiit result; but in such cases, even moi-e than in cases of rape, there woidd be the presump- tion that such wounds were caused by a more unyielding obj<^ct than the penis. In adults the spliincter ani is more readily capable of dilatation than in cluldren ; and for this reason, where an adult permitted the a(,'t of pederasty, tliere might be no evidence of it found in the subsequent i'oudition of the tissues al)out the anus. There are certain cject to wider variations, also, for the reason that the inheritance of a definite sexual inclination must take place fi-om one of two parents rather than from two ; for the necessary conjunction of possible inheritance of opposite sexual inclinations from both parents would necessarily weaken the prob- al)ility of direct inheritance from one parent of a definite sexual inclina- tit)n for one or the other sex. We know that anatomically each sex has in embryo the mor})hological possibility of representing the ojjposite sex; -and likewise each individual must have within his organization the i)ossi- bility of the ultimate develo])ment of the two secondary (psychical) in- stincts. Anatomically, ordinarily one set of generative organs attains complete devel()])ment, with dwarfing of the complementary set, and thus renders the sex definite. This process takes place as a result of hidden organic causes, though these causes are probably intimately connected with the process of nutrition. With the psychical side of sexuality the case is somewhat different. As has been shown, there are many ])ossible sources of variation in the development of the sexual instinct; and more tlian that, actual observation has disclosed the fact that in the Innnan race the development of the psychical pai't of sexuality is profoundly in- fluenced by a definite education, which is usually in harmony with the 554 ^ SYSTEM OF LEGAL MEDICINE. anatomical sex. With tlie recognition of a child's sex this sexual educa- tion begins, and under normal circumstances it is always in harmony with the sex represented by the child. Moreover, that the educational factor is of vast importance in determining an abnormal direction of sexual inclination is abundantly shown by many reported cases. Allowing the importance of education in determining the charac- ter of the developed sexual instinct, we may consider the manner in which its influence is exerted. A long period of the life of the human being is nor- mally asexual. During this asexual period the developing child learns the outward distinguishing marks of the two sexes ; this the more perfectly the less sexual concealment there is. Thus, in a savage state the human being,, learning at once the sexual (anatomical) distinction of the persons around him, and recognizing his own classification, would almost inevitably con- form to the manner of his sex. The only exception to this is where cultiva- tion at the hands of others brings about a deviation. And the comparative ease with which such a deviation can be brought about by directed effort in early years but emphasizes the fact that there the inheritance is usually only of the primitive sexual instinct (for contact). In a higher state of civiliza- tion the distinctions between the sexes are less obvious physically, and more obvious in dress and occupation. Under such circumstances the child learns only comparatively late to classify himself sexually ; and, in consequence, the possibility of sexual perversion is increased. A male child thus might early show a preference for feminine dress and feminine play. This tendency would have in itself no sexual meaning ; but the proclivity might take so strong a hold of the mind as to l)e determinate and serve in itself to pervert (or prevent the normal expression of) the sexual inclination. There would be sexual desu"e, but it would be guided and directed by the inclinations (asexual) previously acquired, provided opposite influences were not brought to bear. Example and imitation are factors which direct the development of the child's mind, and its tastes are determined thus before puberty has awakened sexual feelings. Since education, example, and imitation develop in us all the secondary and higher characteristics of sexuality appropriate to each sex, it would seem that the term congenital as applied to sexual perversions should be used sparingly. However, the accepted classification of psychosexual anomalies, in its. separation of so-called congenital and acquired cases, justly recognizes an important distinction, namely, the separation of cases dating back to^ childhood from those of later origin. The importance of this differentia- tion depends upon the fact that a tendenc}^ arising and developing in child- hood is apt to become so strong and unalterable that it persists as a domi- nant characteristic throughout life, in spite of all artificial efforts to correct or alter it after maturity. This is especially true of the sexual tendency. Should a child develop any kind of sexual perversion, aside from the inher- ent tendency for it to persist, circumstances would favor its continuance. Thus the modesty of cultivated society prevents the recognition of such an anomaly early ; the affected child goes on in the perverse du-ection un- enlightened ; at last, with experience only in the perverse direction, when the normal sexual relations are learned they are not comprehended, or they fail to give satisfaction equal to that experienced in perverse sexual indulgence, and they make no impression on the individual. On the other hand, a sexual perversion acquired late is far more subject to change. SEXUAL CRIMES. 535 In siK.'li a case normal sexual inclinations have been primarily exercised, and they continue the stronger ; perversion has taken place under pecul- iar circumstances, and with a restoration of normal cu-cumstances the normal inclination reasserts itself. Another important fact in psycho- sexual pathology is the relation of sexual perversion to neuropsijrJiical de- generdcj). Observation shTeatest medico-legal interest. Lust=murder. — Only murder comnutted in association with sexual excitement or for sexual <>Tatification is properly lust-murder. The lust may also lead to horrible mutilation of the body after the death of the victim. Lombroso* reports the case of a man named Grassi, who was suddenly seized with a sexual desire for a relative. When she resisted he stabbed her several times with a knife, and also her father and uncle, who souglit to restrain him. He then repaired to a prostitute to cool his sexual desire ; returning', he killed his father and slaughtered several oxen in their stalls. The case of Andreas Bichel, reported by Feuerbach, is also instructive. He killed and dissected prostitutes. Concerning one of his victims he said : " I opened her breast and cut through the fleshy parts of her body with a knife. I then arranged her body as a butcher does a beef. . . . "VMiile opening the body I was so greedy that I trem- bled and could have cut out a piece and eaten it." Another case is that of a man who was examined by Lasegue, Brouardel, and Motet, and exe- cuted : Menesclou, aged twenty, murdered a girl aged four. One of her forearms was found in his pocket. The head and entrails, in a half- burned state, were taken from the stove, and other parts of the body were found in the water-closet, but the genitals could not be found. M. became embarrassed when questioned about the latter. His sexual his- tory was to the effect that he did not indidge in intercoui'se with women, but practiced mastui-bation and sodomy. His mother and an uncle were insane. M.'s own history was otherwise that of a psychopath. How unbridled lust may lead to anthroj^ophagy is shown by the following case, reported by Gorget: L., aged twenty-foui*, caught a girl of twelve in the woods and violated her. He mutilated her genitals, tore out her heart and ate of it, drank her blood, and buried the remains. He confessed his crime and was executed. In some cases sexual violation is omitted, the mutilation of the vic- tim being a full sexual equivalent. The case of Verzeni, reported by Lombroso, was such an one. He made several unsuccessful attempts to strangle women, and in the same way murdered three young women. The confession of this degenerate creature is especially interesting for the light it throws ui)on this association of lust and cruelty. The com- ndssion of the nnirders by strangulation gave him an intense lustful pleasure, accompanied by erection aiid ejaculation. He experienced sexual pleasiu'e immediately upon grasping the neck of his victim. Ordinarily, merely choking his victim was sufficient to induce sexual pleasure ; but if the orgasm were delayed he continued the strangulation until death ensued. In one instance he had found great satisfaction in sucking his victim's blood, and he tore out a piece of the calf to roast and eat at home, but hid it. He delighted in smelling and touching the clothes and intestines. Wliile in the act he was in a perfect furor of * The Criminal. 562 ^ SYSTEM OF LEGAL MEDICINE. excitement and oblivions to everything else. The female genitals were a matter of indifference to him, and he never had inclination for normal sexnal indulgence. His perverse inclination was first shown in his twelfth year, when he experienced a peculiar feeling of pleasure while wringing the necks of chickens. He did this frequentl}^ with no other purpose than the induction of sexual excitement, and the early accidental asso- ciation remained determinate and became an uncontrollable im23ulse. He was sentenced for life. Mittilafion of the dead bod}^ out of lust is allied to actual lust-murder in that the mere act of mutilation of a corj^se affords the sexual gratifi- cation that in lust-murder is attendant upon the actual infliction of pain. It is an act of symbolic sadism, performed by a sadistic individual whose moral sense is still strong enough to restrain him from doing violence to the living female. This form of sadism may be combined with an inchnation to actual sexual gratification with the body. The case of Sergeant Bertrand is a celebrated instance. He was of delicate consti- tution and peculiar character. At the age of thirteen his sexual desire became manifest and he began to practice mastiu'bation, in the act sur- rounding himself with imaginary women. He would fancy having in- tercourse with them and then killing them; then he would think of violating the corj)ses. At last he experienced the desire to make his fancies actual. First he made use of the bodies of animals, opening the abdomen and tearing out the entrails while masturbating ; next he killed and mutilated dogs ; and finally he came to exhume female corpses to mutilate them and masturbate. On three occasions he first performed the sexual act on the bodies of females, but he never omitted subsequent mutilation, which was the only act that gave complete gratification. Allied to this symbolic sadism is true tiecropMlia, in which a female corpse is preferred to a living woinan for the performance of coitus. In such cases there is not pure sadism, but it would seem that the idea of feminine submission, which is so strong a sexual stimulus for the male, becomes so intensified as to see its objective perfection only where there is no possibihty of resistance, as in death. StiU such eases may also be dependent upon feticMsm (q.v.), i.e., pathological association of first sex- ual excitement and the idea of a female corpse. The sadistic impulse is often expressed in acts of cruelty that stop short of murder or very serious bodily injury of the victim. Lust is experienced in the mere infliction of pain or at the sight of blood. The Marquis de Sade took pleasure in coitus only when he could draw blood on his consort by pricking her ; and a man mentioned by de Boismont forced his consort to make her genitals bloody by means of leeches be- fore coitus. The latter instance may have been a pure case of feficlihm originating in an early coitus with a menstruating woman. The slighter bodily injuries inflicted on women by sadists for the purpose of sexual gratification vary. It is frequent to observe a desire to draw blood ; but flagellation of the female often sufiftces. It is to be noted that in all the cases of sadism reported in literature the subjects have been more or less markedly psychopathic ; there has always been observed a basis of hypera^sthesia, upon which the perver- sion has been developed by accidental association of ideas. The varia- tions in the manner of expression of the sadistic iuipidse show liow much it is determined by accident of experience. With an original psycho- SEXUAL CHIMES. 5(j;j patliic basis and sexual liyperiTPstlicsia the conditions are favoral)le for th(^ development of sadism, as they are for the develoi)ment of all other forms of psyehosexual perversion. The ease of a young- man reported by von Kraft't-Ebing- ilhistrates lust- ful pleasure at the sight of blood. The patient reniemhcfed his lustful de- light at the siglit of blood as early as his tenth year. He cut and prieked himself to gnin tliis pleasure. The sight of tlie bleeding linger of a female gave his im[)ulsc objective direction, and he nuisturbated while reveling in the fancy of bleeding girls. Finally his sadistic f.uicy extended to the most horrible slaughter of human beings. The act of masturl)ation banished su(;li ideas. He was alwa^^s able to keep himself from attem})t- ing to make his fancies actual. Neuropathic though he was, his sadistic ideas were finally replaced by natural sexual indulgence. The girl-stab- ber of Bozen was a man who destroyed his sexual powers by masturba- tion, and finally developed a substitute for coitus in the act of stabbing with a knife the girls he met on the street. Ilis satisfaction was intensi- fied l)y the sight of blood on the blade. A similar case is reported from Augsburg. The offender had stabbed about fifty girls, but was always careful to avoid doing serious injury. He also found sexual gratification in looking at his collection of knives, swords, etc. A case reported by Dr. Moll is an instance in which flagellation of the female nates and liumiliation of the female were substitutes for the sexual act. The sadistic impulse may be directed only to humiliation of the female, and thus find expression in acts of defilement of the female j^er- son. Frequently this defilement is of the most disgusting charactei- — with urine, faeces, etc. It seems highly probable that the motive which leads to the defilement of women by ink, etc., is a sadistic impulse ; at least all sucli cases should hereafter be examined with a view to discover any possible sexual factor where the per^jeti-ators are men and their vic- tims women. The cutting off of women's hair by force or stealth may possibly have some relation to sadism, but mo]-e frequently it is to l)e referred to erotic fetichism, which is described later. The literature shows that there maybe merely a si/DthoJic satisfaction of the sadistic imjiulse. Thus the sexual gratification souglit may be found in acts and situations which suggest the infliction of i)ain or hu- miliation, but in which there is no actual suffering. In such cases the mere idea of suffering endured by the passive person, suggested b}^ a situation artificially created, suffices to give sexual satisfaction. Cases of this kind can seldom give cause for medico-legal investigation, but where such situations were forced on a person legal questions might arise, as in a case reported by von Krafft-Ebing, where a certain Aus- trian count was convicted of giving ])ublic offense by forcing a young girl who accompanied him into a pul)lic garden to kneel down, implore him with folded hands, and lick his boots, at the same time demanding that she actuallj'' kiss him ad wtfes. The sadistic inclination may be directed toward any living ol^ject, whether the affected individual is aware of its sexual coloring or not. Thus there have been many cases of sadistic whipping of children by male teachers ; and the torture of animals has not infrequently been found to depend upon sexual gratification experienced in this wanton infliction of cruelty. In young persons innocent of knowledge of the sexual relations the latter tendency nuiy be indidged with unconscious- 56i A SYSTEM OF LEGAL MEDICIXE. ness of its true significance ; in more experienced men it may be practiced as a substitute for tlie satisfaction experienced in cruelty practiced on females. Von Ki-aift-Ebing regards cases in which the mere sight of blood, death, etc., excites sexual feeling as instances of such original con- stitution of the vita sexualis that the relation between these impressions and lustful feeling is a dii'ect or immediate one ; but to exclude patho- logical association, even in these cases, is impossible ; and it seems su- perfluous to assume the existence of an unnecessary factor to explain the phenomenon. Though sadism is distinctly foreign to the psychical character of women, it is occasiouall}' observed in them. The tendency of women to bite at the height of sexual excitement is well known, and that this may become intensified to a pathological degree is illustrated by the case re- ported by Moll, where a young wife found her most intense pleasure in biting her husband until the blood came, and who was best satisfied if she bit her husband and he bit her. As von Kralft-Ebing points out, many of the Messalinas of history were celebrated for their lust and cruelty ; and in some of these instances the conditions suggest that there was complete inversion of the feminine character, with excessive develop- ment of the sexual characteristics normal to men. In order to prove the sadistic natui'e of acts of cruelty it is always necessary to demonstrate distinctly their association with true sexual excitement. We know that cruelty is a very frequent manifestation, and that it is ordinarily an independent psychological phenomenon ; there- fore it cannot be j^resumed that the sexual factor is operative, save in those cases where peculiar circumstances indicate the existence of this remarkable pathological association. Where atrocious or peculiar acts of crueltj^ can be explained upon no gi'ound of sane motive, and the in- dividual is to aU. intents sane, there would be some reason to suspect the hidden influence of a sexual impulse, more especially if the acts were in an}' way related to sexual ideas. Passivism. — This terin is applied to a psychosexual condition that is the counterpart of sadism : sexual gratification is sought and experienced in suffering personal pain or \-iolence, or theii' psychological ecpiivalents, at the hands of a person of the oppo.site sex. In this perversion of the sexual instinct the idea of subjection to the will of another becomes the most intense stimulus to sexual feeling, to the partial or entu-e exclusion of all normal stmiuli. "V^Hiere this subjection is experienced, sexual orgasm is induced partially or completely. Passivism is most striking when it is exhibited by men ; for it is to be regarded as one of the psychical characteristics of women, whose sexual role is physiologically a passive one, with which the idea of sub- jection to the masculine will is a natural psychical association. Daily experience is sufficient to show that woman finds her completest sexual satiety in being sul^jected to the masculine sexual domination, and the degree to which this characteristic is exhibited by females within reason- able limits may be taken as a measure of their femininity. Such a char- acteristic manifested by a man, however, is strikiiigly abnormal, and it can but be regarded as one varietj^ of perversion on the way to comjjlete jisychosexual inversion. However, the many cases thus far observed in men have been but infrequently associated with fully developed sexual inversion ; as a rule, men thus affected exj)erience a desii-e for subjection. SKXIAL CHIMES. OG.J humiliation, uiid abuse, going- to tlio extent of violence and cruelty, at the hands of women. With this thei'c nuiy he various degi-ees of imp.iir- ment of virility up to eompleti^ ]>syeliieal impotence. Tlie satista(;tion of this strange sexual inclination is usually sought l)y indueing women to perform the ])art necessary to insure satisfaction : prostitutes are hired to perform flagellation or to carry out various cc^medies in which the individual is placed in the role of one subjected to the grossest violence and indecencies, or one humiliated by a mistress to an extreme degree. Von Krafft-Ebiug regards cases of ]>assivism as psychol()l»'uicnit(d. We liave seen, however, that such a division is more or less difficult, if not impossible, and that a more practical and less prejudicial means of clas- sification is to separate them into 7(/;'? (acquired) and earhj (congenital) cases, in accordance with the period of the lii'st manifestation of the in- version. * Wiener Med. JVochoiscJu-ift, 1879, No. 23; Psiichopatlua ScruaUs, p. 172. t Oj>. clt., p. 131. 570 ^ STSTEAl OF LEGAL MEDICINE. All observers agi'ee in the conclusion tliat a neui'opatMc nervons system, congenital or acqnii'ed, is a prerequisite for the development of sexual instinct for the same sex (homosexuality). To this predisposing neuropathic condition some exciting cause is added. The most impor- tant exciting or contributing causes are excessive masturbation, feai- of pregnancy, and venereal infection. According to von Ki-afft-Ebing, the signs of a nem-opathic constitution which may lead to sexual inversion are prematm-e development of sexual desii-e ; sexual hyperesthesia ; func- tional and anatomical signs of degeneration ; neui'oses (hysteria nem-as- thenia, epileptoid symptoms) ; psychical anomalies even to degrees of weak-mindedness and moral insanity; neui'oses and psj^choses in pro- genitors. The same author differentiates foni' degrees in the develop- ment of the inversion, applicable alike to early and late cases : 1. With predominating homosexual feeling there is a, trace of feeling (heterosex- ual) for the opjDosite sex (psychosexual hermaphroditism) ; 2. Exclusive homosexuality limited to the vita sexualis; 3. The whole character corresponds with the incongruous sexual feeling; 4. The form of the body, aside from the genitals, corresponds with the anomalous sexual inclination. Since in any case sexual inversion is but a phenomenon arising from a neui'opsychopathic condition, as pre^dousty indicated, it is seldom an isolated manifestation, but is most frequent^ observed in combination with other sexual perversions. In accordance with this, the medico- legal questions arising in sexual inversion may be identical ydWi those raised in the sexual perversions previously considered. The further pos- sibilities of a criminal character are related to the crimes of jiederasty. The indi\ddual affected with contrary sexuahty satisfies himself with men by means of passive or mutual onanism, or by coitus-like acts {coitus inter femora) ; if active pederasty is performed, it is only as a result of intense sexual desire, or out of msh to please another. Passive peder- asty may be performed by contrary sexual individuals to please the act- ive party, or out of lust where they feel themselves entu-ely in the femi- nine role. To distinguish such cases from pederasty not dependent upon a pathological condition, it is but necessary to exclude the existence of psychosexual inversion, and to remember that where this crime is per- formed apart from perversion it is as a means of sexual indulgence in the absence of oj)portunity for natm-al satisfaction, and as a new means of sexual gratification where natural methods of sexual pleasure have been exhausted by excess. Non-pathological passive pederasty is prac- ticed onlv for gain. The "follo^dng uniiulilished autobiography will illustrate a case of sexual inversion of early development : " From my earliest childhood I have exliibited an abnormal sexual tendency. I have never loved a woman — never experienced a trace of sexual feeling for a woman. Yet I cannot say that I have a Iwrror femi- narnm. I do not associate with ladies, not because I dread them, but knowing my condition I feel so inexpressibh^ unhapp}^ by reason of it that I avoid their society. I have never attempted coitus with a woman, because I have no desire, and then again I know it would be impossibk-. Neither do I consort criminally with men. My desires are for men ex- clusively, but they have never yet been so strong that I was unable to control my actions. Of course I avoid temptation. In all my thoughts SEXUAL CRIMES. 571 (s<'xually) I I'egai'd myself in a passive role. I am eff(,^minate in action and appearance, thon^li I am told I am less so than froA'e that a wi-ong treatment has been piu-sued ; and from the f lu'ther fact that the diagnosis in a large number of instances can only be cleared up by observing the results of treatment. Under these cii'cumstances, therefore, the treatment must be largely experimental and consequently more or less at variance with any set of hard and fast rules which might be urged as applicable to the case. Errors of Judgment. — Wliile the surgeon is bound to give his patients the benefit of his best judgment, he is not lial:)le for a mere error of judg- ment, unless it can be shown that the latter is so gross as to be incon- sistent with reasonable care, skill, and diligence, t * 14 Am. & Eng. Encvel. of La-n-. 76. t Westxs. Martin, 31 Mo. 375; Howard vs. Grover, 28 Me. 97. SURGICAL MALPRACTICE. 577 Unusual and Extraordinary Emergencies and Surroundings. — Tlie surgeon is compelled oeca.sioiiully to act under circuinstances of the most trying and extraordinary character. .His own safety may be imperiled at the very moment he is called upon to act in ])ehalf of another. The surroundings upon a hattle-field or a railroad wreck are not conducive to an even balance of mind, or calculated to assist in ])ringing a cool and calm judgment of the necessities of the case to the aid of the attendant. Local, t(!mporal, and external conditions of various kinds, as well as the necessity for acting at once; the exigencies of a case demanding prompt action, and that perhaps with material of a hastily imj)rovised character and ill-adapted to the emergency, may prevent the surgeon from making use of knowledge which he really possesses, or from showing that ahility which under nu)re favorable circumstances he would exlnhit. Moreover, the necessity at times for the rapid performance of an operation, as, for instance, tracheotomy, or the prompt application of a remed}^ in an emergency, may be al)solutely incompatible with the exercise of due care and precaution against accident. In addition, the importunities or expostulations of the patient or his friends may serve to bias, or at all events to disturb, the judgment of the surgeon and tend to lead him into error. Latest Methods and Appliances. — Where the exigencies of the case will permit, and where there exist no extenuating circumstances such as have been already dwelt upon, the surgeon, in the perfornjance of all surgical operations, is bouiul to bring at least the ordinary care and skill possessed hy those who practice in the same locality or have access to the same sources of information which he can avail himself of.* He must possess and exercise in an intelligent and practical manner that degree and amount of knowledge and science which the best authorities have declared to be the result of their observation, experience, or re- search, up to within a reasonable time of the date of the error of com- mission or omission which is at issue. t Response to a Call and Duration of Attendance. — Reproach is some- times cast upon the surgeon for failiu'e to respond to a call for profes- sional services in urgent cases. It is his implied duty, if he is the regular attendant, to properly attend the case so long as it requires attention, unless his services should be no longer acceptable to the patient, in which case a formal dismissal will be in order. He may Likewise vol- untarily cease his attendance upon the case at any time upon giving rea- sonable notice of his intention to do so, if further care is necessary. It is also within his province to determine when attendance may be safely and properly discontinued, but the same rule in regard to the exercise of ordinary care and skill likewise holds good in this connection. Special contracts may be made, however, between the surgeon and the patient, limiting the attendance to a longer or shorter period, or to a single visit, or governing the frequency of the visits.f * Grnnini vs. Bonier, 56 Ind. 497; Kchci/ vs. Hai/, 84 Ind. 189. t Elwell on Mal]irac1i(T ; Am. Law Eeg. (N. S.) 774; 8 East (Eug.), 347; 1 H. Bl. (Eng.) 61 ; MrCaiidlrss vs. McWIm, 22 Pa. St. 261; 27 N. H. 460; 13 B. Mon. 219; Shearman & Redfiold, vS 440; McLaJoii vs. Adanis, 19 Pick. (Mass.) 333; Cnrpeuter vs. Blake, 60 Barb. 448 ; 'Patleu vs. Wiqqhi, 51 Me. 594; Rex vs. Long, 4 C. & P. (Eug.) 423; Shilvv vs. Bokvr, 2 Willes (Eng.'),' 2.j9. X See Ballon vs. rrcacott, 64 Me. 305; Todd vs. Meyers, 40 Cal. 357. 578 ^ SYSTEM OF LEGAL MEDICINE. No Implied Warranty to Cure — Express Stipulation. — The mere ■employment of a sm-geon does not, in the legal sense, imply a contract to cure,* although the surgeon may, at his discretion, contract to per- form a ■ cure absolutely, in which case he can be held as a guarantor of success.t The profession, however, has always looked upon such bargains with disfavor. The surgeon, when he enters upon the charge of a case with dignity and a due regard for his professional standing, is not in any sense supposed to insure a cure, and hence is not to be tried for the result of his efforts, pro\dding he treats the case with rea- sonable diligence, care, and skill. More than this may be expected and demanded if an express stipulation exists, precisely as in common con- tracts between individuals in commercial life. The mere fact that the surgeon attends for a fee simply implies that he shall exercise care, dili- gence, and skill in all his acts, and that these shall be such as are best calculated to restore the patient to health, and least likely to injuriously affect him. Equal Amount of Time and Attention. — The surgeon is not always bound to bestow an equal amount of time or degree of attention and skill upon all who come under his care, much less is it necessary that he should carry these to the same extent as some other medical man might have done. In order to render him hable it must be shown that damage has been inflicted and that there has been a want of competent and ordi- nary care or skill, or an indifference to the patient's best interests. Even an admission on the part of the sui-geon himself that there has been a lack of care on his part does not alter the case so far as is concerned the necessity of proving that there was such lack of care, and that the patient suffered in consequence thereof. The i)roposition that the surgeon is not bound to give the same or equal care and attention to all cases is based upon the fact that each case is to be individualized, and that the peculiar mental qualities of one patient, although not very ill, will demand more attention tlian required by another who is more seriously ill, yet not so profouudly impressed mentally as to require oft-repeated assurances of continued well-being. So many factors may enter into the consideration of the case in this con- nection that it would be absurd to permit a standard to be set up based upon the patient's own ijreferences. It is not sufficient that the patient asserts that he did not get as much care as he desired : he must show that he was damaged by insufficient care or inefficient treatment, and that these were avoidable on the part of the attendant. Gratuitous Services. — Tlie fact that a surgeon renders services gra- tuitously does not affect his duty to exercise reasonable and ordinary care, skill, and diligence.f Treating a patient gratuitously does not give the surgeon license to treat him other than in a scientific and careful manner and with due regard to his best interests. In fact, failure on the part of a surgeon to render a bill or make some claim for compeiisa- * Teft vs. Wilcox, G Kan. 446 ; Heese vs. Knippel, 1 Mich. N. P. 109 ; Getchel vs. HUl, 2l"Minu. 464 ; O'Hara vs. Jrellft, 14 Neb. 403 ; Leif/hfoii vs. Sargent, 27 N. H. 460 ; CraiffYH. Clianiherf:, 17 Ohio St. 253; J3/w.s' vs. Lmiq, Wright (Ohio), 351; Grvidle vs. Bud, 7 Ohio, pi. 2, 123. t Eh/ vs. inibnr, 49 N. J. L. 685; Gallahcr vs. Thompson, Wright (Ohio), 466; Sniiih vs. Hijdc, 19 Vt. 54. X McXcrhis vs. Lowe, 40 IlL 209. tiilUllCAL MALl'liACTIVE. 579 tion for the treatment of a case, and the inability on his part to explain tliis otlierwise than np<^)n the g-roiind tluit the patient was a liospital or dispensary patient east' wliich came under his care as such, ininn- phreij, 9 Coim. 209; MeXcrin vs. L- fansed by the negligence ov want of proper care and skill on the part of the defendant.* Partnership Liability. — In case two or more snrgeons are associated together in joraetice as partners all are liable for malpractice by any member of the firm.t Action Barred by Recovery for Services. — A recovery ])y a surgeon for his services ^\\\\ l)ar a future action for malpractice, as a rule. Ex- ceptions to this will l)e found in some States where it is held that if the recovery be by confession or default it is not a bar. % CRIIVnNAL LIABILITY FOR NEGLIGEXCE OR INOSCOXDUCT UNDER SPECIAL STATUTORY PRO\^SIONS. As previously stated, in the United States there are penal statutes, differing somewhat in the different States, which provdde for the pun- ishment of medical practitioners for negligence or misconduct, in their professional capacity or in tlie course of their employment or business, which causes death. The law is held to apply, in sonje States, to dealers in drugs and medicines who by carelessly labeling a deadly poison as a harmless medicine inflict an injury or damage to persons without fault on their i:)art. The following extracts bear upon the point of criminal liability for negligence : " A person who, by any act of negligence or misconduct in a business or employment in which he is engaged, ... or by any unlawful, negli- gent, or reckless act, . . . occasions the death of a human 1 )eing. is g-uilty of manslaughter in the second degree." The aliove i^aragraph has been held to apply to druggists as well as to practitioners. § " A physician or surgeon, or person practicing as such, who, being in a state of intoxication, without design to cause death administers a poi- sonous drug or medicine, or does any other act as a physician or surgeon to another person which causes the death of the latter, is gnilty of man- slaughter in the second degree." || GENERAL CRBIINAL LLABILITY AT COJDIOX LAW. Under the common law, as well as under special statutory enactments, a physician or surgeon who, by his culpable negligence, causes the death of his jiatient is guilty of manslaughter. A person who nnla^N-fully en- gages in the practice of the profession of medicine and causes death by the application of means which he may even beheve will be of benefit to * Wcnger vs. CaUlcr, 78 111. 275. t Uyrne vs. Erinu, 27 S. C. 22G: 55 Am. Rep. 15; WhUtalcer vs. Collins, 34 Minn. 299. .. t Rrnscqnle vs. Biiers. 52 Wis. 650; 38 Am. Rep. 775; Skiies vs. Bouuci; 1 Cin. Sup. Ct. 4G4 ; (iohlc vs. j}ill<>ii, 80 Iiul. 327 ; 44 Am. Rep. 308 ; 14 Am. and Eng. Encyel. of Law, 83. SS Penal Code of New York, ^ 195 ; Thomas vs. TTiiichester, 6 N. Y. 397. II Penal Code, s^ 200. 584 -J SYSTE2I OF LEGAL MEDICINK the patient, would be guilty of manslaughter.* Gross ignorance, gross'i carelessness, rashness, or want of proper precaution on the part of such a pretender constitutes manslaughter at common law.t A person who may assume to act as a physician or sui'geon is not criminally liable for the death of a patient caused by the medicines which he administers, provided he acts in good faith and to the best of his abilities, and does not pretend to be a physician, and is known not to be such-i In the absence of statutory provisions upon the subject, the general rule applies. Under this a regularly quaMed physician and surgeon legally authorized to practice his profession cannot be held criminally responsible for an honest error of judgment in the treatment of his- patient, although such treatment may cause his death. § Failure on his part, however, to meet the requii-ements of ordinary skill and diligence, the death of the patient resulting from his gross ignorance, inattention, or carelessness, or from criminal misconduct, being shown, he would be held guilty of manslaughter at common law, if not under statutes. || Punishment through a Criminal Action not a Bar to Recovery in a Civil Action. — Finally, it is to be noticed that in case a physician or surgeon suffers trial and punishment for malpractice, either under special statutory enactments or at common law, this does not constitute a bar to a civil action which the patient may bring against him for damages arising from such malpractice. The fact that the defendant had ah-eady suffered punishment for the offense would not even affect the rights of the plaintiff in such an action in recovering punitive damages, where,, under the circumstances, such damages are allowable.*fj THE MISHAPS OF SURGICAL PRACTICE. GENERAL CONSIDERATIONS. There are certain accidents occurring after injuiies and operations which may be looked upon as unavoidable to a great extent. Among these are to be included traumatic delirium, delu'ium tremens, fat em- bolism, and intoxication by fibiinous ferments. Among the accidents which may be considered as unavoidable under some circumstances and avoidable under others, may be mentioned tetanus, hemorrhage, sepsis,. and those relating to the use of anaBsthetics. Traumatic Delirium. — Traumatic dehrium may attack old and en- feebled patients as well as those who were in perfect health prior to the occurrence of the accident. It may resemble the somewhat peculiar- form of delu'ium which attacks drunkards following an injurj^, the symp- * Marsh vs. Davidson, 9 Paige (N. Y.), 579. + 1 Hales, P. C. (Eng.) 429 ; 4 Bl. Com. 197 ; Bex vs. St. John Lonfj, 4 C. & P. (Eng.> 432 ; Hex vs. Van Butcliel, 3 C. & P. 333 ; Bex vs. Ellis, 2 C. & K. Eng. 479 ; Bex vs. Spiller, 5 C. & P. 333 ; Bex vs. Williams, 3 C. & P. 633. X State vs. Shultz, 55 la. 628 ; 39 Am. Eep. 187. § Field's Medico-Legal Guide, p. 192. II Wheeler's Criminal Bejports (N. Y.), p. 312; Commonwealth y?,, Thompson, 6 Mass. 134 ; 11 Am. Rep. 122. % Hendriclcson vs. Kingsbury, 21 la. 379 ; Corwin vs. Walton, 18 Mo. 71 ; Hadlcj/ vs.. Watson, 45 Vt. 289; Boberts vs. Mason, 10 Ohio St. 277; Childs vs. Bralie, 2 Met. (Ky.) 146; Field on Damages, U 436-439. SLRGICAL MALl'llACTK K. 585 tonis of iiial)ility to sleep, anorexia, and delusions bein^? present in hotli. Prominent among- the latter may be mentioned tlie grasj)ing at imag:i- nary small animals and atti^mpts to escape from imag'inary dangers. The latter are much more pronounced in delirium tremens, however, than in traumatic delirium. Fat Embolism. — Fat embolism occui's probabh' in almost all fract- ures to a greater or lesser extent ; in addition it may occur where there is injury to the stomach or T)owels while fat wliicli is undergoing- dig:estion forms a portion of the contents of the latter. In the case of fractures the fat is derived mainly from the medullar}' cavity, and in additi(jn to this source it may be deri\-ed, to a certain extent, from the sul)Cutaneous connective tissue. The fat is forced into the opened venous channels and is taken up and carried along- by the blood-current. Even in patients who die almost immediately follomug injuries involving fi-acture of bones, the drops of fat may be demonstrated in the lungs by post-mor- tem examination. The particles of fat are broken up as they pass through the capillaries, becoming reunited in the lai-ger trunks, until at last they are excreted by the kidneys. (Mausell Moulin.) While in the vast majority of cases no s^anptoms may arise, it occasionally happens that collajise comes on, too late to be attributed to shock, but superven- ing- after an interval of several hours. Dyspnoea and syncope, with rapid fall of temperature, are the characteristic s^nnptoms. Intoxication from Fibrin Ferment — The causes of intoxication from fibrin ferment are obscure. This is looked upon as one of the fever-producing- agents not necessarily of a septic character in the sense that they depend upon an infective organism. The source of the filirin ferment is the broken-down blood-clot f ollo^^'iug hemorrhages. It follows subcutaneous injuries in which decomposition in the sense of putrefac- tion does not take place. It produces one of the varieties of traumatic fever, the temperatiu*e rising- in proportion to the amount of the extrav- asation. It is more than probable that other substances, set free from crushed and bruised tissues, likewise give rise to traumatic fever. The height of the fever is reached in aliout twenty-four hours ; its diu-ation ■depends upon the amount of irritant material present and the extent of its absorption. In the average cases the fever subsides in about forty- eight hours, but it may last for a week or more, the fever, however, steadily falling after the first twenty-four to thii'ty-six hours. It may assume a remittent type. Tetanus occurs most frequently in wounds accidentally inflicted, par- ticularly in j^unctured and penetrating wounds, and in those in which a foreign body renuiins behind. Its existence is now believed to dei)end upon the presence of a special organism, the BdciUiis fefaiii. A variable length of time is occupied in the period of incubation, according to the number of l)acilli introduced (Watson ChejTie), the location of the point of infection, the anatomical characteristics of the siirrounding tissues, and the capacity of the different tissues to yield the ptomaines under tlie influence of the bacillus. It is also probable that the degree of vini- lence governs, to a certain extent, both the duration of the stage of incu- bation and the severity of the attack. The question is sonu^times raised as to the propriety of remo%'ing foreign bodies which have remained in sifii for perhaps months in those patients in whom these bodies are supposed to be the cause of the dis- 586 -i SYSTEM OF LEGAL JLEDICIXE. ease. The first impnlse is to remove tlie foreign body at once, but tliere is reason for believing that this is not always necessary, and in some instances may do hai-m, the disease being greatly aggi-avated by even the slightest external impressions. The modern methods of ti'eatment of the disease are based, in fact, npon an endeavor to absolutely abolish everything which in any way can produce an impression upon the nerves of special sense, or the sensory nei'ves in general. If the foreign body is encap.sulated and an incision is necessary for its removal, this course would be more than likely to increase the dangers of the disease in the manner indicated. This rule, however, does not apply to the removal of the foreign body as a preventive measure ; and as the bacillus of tetanus requii'es the exclusion of oxygen in order to grow, it is evident that a pimctured wound quickly closed offers just the conditions appropriate for the reproduction of the germ, if it has been introduced into the depths of the wound. In wounds of this character, particidarly if they have been received in a locality where tetanus fi"equently follows tri\"ial wounds, as on the south side of Long Island, the wound should lie weU cleansed, and enlarged if necessary for this piu-pose, and ti*eated with tampons of gauze wi-ung out of a 1-1000 bichloride-of-merciuy solu- tion, and healing by gi-anulation encoiu'aged, rather than union by fii*st intention. Uncontrollable Hemorrhage. — This is among the most nnfortimate accidents of surgeiy. Rigidity and biittleness of an artery, or its retrac- tion beyond oui* reach, in spite of dilatation or even enlargement of the wound, may bring about this result. HemoiThages fi-om large venous trunks are the most dangerous. Before the fact that hemorrhage from a large vein could be influenced by ligature of the corresj^onding arteiy was established, bleeding from the internal jugular or femoral veins was considered as almost necessarily fatal. In hemophiliacs the sUghtest operation may cause an almost uncon- trollable hemorrhage. The apphcation of the actual cautery is most use- ful, and compression is sometimes efficient. If the compressing medium is such as to imitate the finger, i.e., impermeable, elastic, and easily cleansed, a great advantage may be gained by its use. A bunch of cot- ton or a soft sponge, WTapped in rubber tissue, the layers of the latter being gummed together by moistening their edges with chloroform and pressing the moistened sm-f aces fimnly upon each other, answers an excel- lent pui-jiose. Such a tampon, if kept apphed so as to make firm com- pression and to dam back the flow of blood fi-om the point at which it escapes, will be found an efiicient means in a certaia proportion of cases. The mo.st rapidly fatal cases of hemorrhage are those in which septic processes — gangi-ene, etc. — invade the structiu-es of the vessels them- selves. The operation of transfusion of blood requires, in order to carry out the necessary precautions and technique, the consimiption of so much time that siu'geons are coming to have less and less confidence in this procediu-e as an available means of combating the evil results of excess- ive loss of blood. AVithout due preparation and the employment of proper instruments, and even ^vith all these conditions fulfilled, there will occasionally occur such aecid«Mits as the injection of coagula or of ah- with the tran.sfused blood. "VMiile the first-named may be avoided in saline infusion, without due care the second may occm\ As to how much aUltClCAL MALriUCTlt'E. 587 benefit may be derived from transfusion of blood, or saline infusion in a given case,' or how niueli the surgeon may be held responsible from the scientific; standpoint for failure to employ it in fatal cases, is yet a matter of doubt. As far as my own exi)erience goes I have never seen a case of acute aiuemia benefited ))y either of these procedures that, in all pi'ob- abiHty, would not hav(^ done well without such interference. Certainly a nnich larger percentage of recoveries in extreme cases nmst be recorded before a sui-gcon can be justly blamed for omitting to use them. Sepsis. — Within the last quarter of a century there have been dis- coveries made and j)rincii)les established in the treatment of so-called wound diseases, or se(jiu'la^ of wounds, which have almost completely changed the science and art of surgeiy, and increased the responsibility of the surgeon to an extraordinary degree. Discoveries in the treatment of interual diseases, or of methods of preventing them, can never bring to the medical practitioner that degree of increased responsibility which has characterized the introduction of those new principles in the treat- ment of wounds to which I refer. The reason for this is ob\dous : the medical practitioner never prodvices the conditions which render possible the presence of the disease which he has been called upon to treat, and hence his measure of responsibility does not extend, to an extreme de- gree, to the prevention of the disease. The only exception to this, per- haps, will be found in those comparatively rare instances in which, dur- ing the prevalence of an epidemic, such a demand is made upon the medical num. But, as a rule, he finds the enemy ah-eady present and intrenched, perhaps, behind what may seem an impregnable line of de- fenses, and, feeling no responsibihty f(jr his presence there, his dut}' is simply to dislodge him. The same remarks might apply to the surgical practitioner in his rela- tion to wound treatment if it were a fact that the wounds Avhich he is called upon to treat were the result of accident, or were made by others than hiniself. But, as a matter of fact, two thirds of the wounds which come under the care of operating surgeons are made by the sui-geons themselves, and hence his responsibility for theii- treatment. Further than this, it has been demonstrated that ahnost all disturbances of the repair of the wound itself, and in addition those of the general system with their dread results, known under the general term of blood-poison- ing, are due to putrefactive processes which have their origin in ferment- ative conditions which have been familiar to us for many years. With the discovery of this fact, and the means of preventing the occurrence of the train of events leading up to its full development, began new obligations and responsil)ilities. From the earliest times, without exactly knowing why, surgeons prac- ticed occlusion of wounds, and in true empuical fashion lauded first this and then that ointment or lotion, always, however, clinging to the idea that the latter must cover \\\e. parts and " protect " them. Wlien the idea that contact with the air caused mischief in the wound was thought of, the temperature of the air was generally considered to be the origin of the troul)lc ; and even now, among the laity, it will Ik^ found, as the result of the teachings of earli(>r authorities, that any mishap, such as erysipelas, occurring in a wound is attributed to ''catching cold." Ambroise Pare added to the theory of cold the belief that the air carried with it certain miasms ; and Benjamin BeU, in later times, taught that gases, mingled 588 -^ SYSTEM OF LEGAL MEDICINE. with the air, were a potent source of evil. UiidonLtedly the large and varied experiences of these older surgeons led them to plan and adopt many methods which in the light of our present knowledge would pass fairly well for antiseptic procedures ; and without doubt the use of wine, turpentine, brandy, alum, common salt, etc., relatively efficient antisep- tics in their way, was by them considered the essential portions of the balsams and ointments then in use, although they scarcely dared to omit what we now regard as the superstitious and ridiculous elements of these compounds, such as serpents, earthworms, human fat, etc. In the earliest times one thing seems to have been entirely lost sight of, namely, the intrinsic tendency on the part of wounds to heal if left alone. No one dared trust anything to nature, and, in the absence of the usual and popular measures directed toward making the flesh grow and the wound cicatrize, it was imagined that all sorts of evil would cer- tainly occur, and that healing would not take place. In those times, like- wise, there seems to have been a dread of healing by first intention or immediate union. Tents or pledgets of lint were crowded constantly into wounds to keep their edges apart, for fear of pent-up Immors giv- ing rise to constitutional disturbance — fever, etc. Thus it will be seen that the importance of drainage to the parts was not overlooked. Among the common people of some country districts, it is considered a great advantage to have a wound "heal from the bottom," as they express it. At the present day the putrefaction of discharges in wounds consti- tutes what is known as a septic condition of a wound. This putrefaction depends upon a fermentation, which may or may not be accompanied by the development of offensive odors. Fermentation, according to Fownes, may be defined as a "new arrangement of the elements of an organic compound, and the consequent formation of new products." Changes coming under the head of this definition are known as the result of what is termed catalysis. Ferments are divided into two classes, one receiving the name of "chemical ferments," while the term "vital" is usually applied to the other. In the catalytic change known as chemical fermentation the decom- position of one body is effected by the mere presence of another, the latter remaining unchanged. These ferments, as has been again and again demonstrated, have not the power of self -multiplication. _ Familiar examples of chemical fermentation may be cited in the action of the pepsin of gastric juice, the ptyaline of saliva, etc. On the other hand, the ferments known as vital ferments possess the power of self-inulti- plication in a remarkable and unhmited degree. The yeast-plant is the most familiar example of this last-mentioned class. In 1831 Braconnet advanced the opinion that microorganisms acted as vital ferments, or that they produced in the process of self-multipheation virulent prin- cijjles which acted as such, although this had been suggested in the beginning of this century. In the next five years followed Downes's discovery of the presence of microscopic organisms in the secretions of certain venereal sores, and during the following fifteen years Fnclis and Pollender demonstrated tlie presence of bacteria in tlie blood of some of tlie lower animals suffering with septic diseases, notably of cattle dying of the disease known as charl)on. But it was reserved for Louis Pasteur, in 1861, to bring out from the mass of imperfect knowledge of the sub- SURGICAL MALPRACTICE. 589 ject at that time availal)le, and to add thereto as the result of his owu brilliant work, facts which led at ouce to a proper coiiceptiou of the role played by these microorganisnis in the production of disease. The theory of the i-elation of ])uti'efaction to fermentative i)rocesses was naturally ap})lied to patholo^iical conditions at once, and the genius of Lister applied the principle to th(^ explanation of certain phenomena following- wounds involving the surface ehc)i CJiinirgie, Band xi. 598 ^ SYSTJiM OF LEGAL MEDICIXE. exclusively in cases of affections of the heart not combined with respii-a- torv distnrliances, and chloroform in affections of the respii'ator}* organs with hypertemia of the tracheal and bronchial mucous membranes, or other obstacles to res]3u*ation. Even' such contraindication, however, is only relative, each ease being carefull}- considered in relation to the si^eeial conditions present. In urgent cases, such, for instance, as strangulated hernia, it may occur that either one or the other may be employed from force of cii'cum- stauces. While the question of i3roper selection of the anaesthetic may be of importance from the scientific standpoint, its relations to possible charges of neghgence, in the present state of oiu' knowledge, can scarcely enter into the controvers}'. Chloroform Idiosyncrasy. — There is a condition known as the chlo- roform idiosjTicrasy, which, however, can only be recognized during the attemj)t to administer this anesthetic. Soon after the first inspira- tion the patient becomes pale and springs from the talkie with terror and great anxiety, declaring that he is suffocating. Almost immedi- ately he passes into a swoon, from which he is aroused ^^ith difficulty. At the same time the pupils become dilated, and strabismus may occur, with clonic convulsions of the upper and lower extremities. On the other hand, some patients exhibit a sort of chloroform or ether hun- ger, inhaling immense quantities in a short time by means of extraordi- narily vigorous respiratory efforts. Both of these classes of cases reciuii'e careful watching on the part of the anesthetizer. In the fii'st the anaes- thetic agent should be changed to ether, and it may be necessary to abandon for the time being all efforts at anfesthetization. Patients should be watched carefully for several houi"s after anes- thetization, particularly when chloroform has been employed. Dyspnoea and cardiac failm-e may demand attention. Quantity of Ansesthetic Employed. — When accusations are made that unusLially large cpiantities of the anesthetic agent have been used, it would be well to bear in mind Mair's * statements bearing upon this 23oint. This author states that patients have inhaled 160 grams of chloro- form in seven hours ; 1023 grams in twenty-foui" hours in another case ; in another, suffering from tetanus, 700 grams in twenty-four hours ; in another, 1000 grams in twelve hours; a woman in the puerperal state remained chloroformed for thii'teen hours, 200 grams being used. In- stances are recorded where patients haliitually took 500 grams daily for five or six days without injury. A ease is related by Nussbaum in which this siu-geon anesthetized with chloroform a patient fifty-thi-ee times for the purpose of passing uretln-al sounds. This patient succumbed to the fiftj'-fourth anesthetization. Upon this occasion laughing-gas was employed. The post-mortem examination showed disintegi^ation of the blood-corpuscles, etc. Methods of Ansesthetization. — As to methods of anesthetization by means of chloroform, authorities are agreed that this agent should be given largely diluted ■s\'ith atmospheric air, and that it should never be I)oured but always dropped upon tlie napkin or mask. The pulse should be carefuUy watched, and note made of au}^ change of color in the face, the occurrence of superficial breathing, or the supervention of loud snor- * Gerichtlicli-mcdiciriisclie Casuistic tier Knnstfehler. srnair.iL mali'Ractick. 599 iiig-. If the pulse beeomes weak, tlie respirations shallow or stertorous, or the color i)ale or livid, the cliloroforui must he at ouce withdrawn. Coini)lete narcosis is announced l»y relaxation of the inusch's and the absence of oeular retlex. Precautionary Measures. — Precautionar}- measures consist in i)lac- ing the patient in the horizontal position ; by some surg-eons it is even required tluit the head be lowered, the body assuming an angle of forty- five degrees. The precaution relating to an empty condition of the stom- ach has already been alluded to. Obstructions to full respiratitm, such as the presence of a collar, or a cravat, or a tight neck-band of the shirt, etc.. should be removed or loosened. Treatment of Dangerous Chloroform Narcosis. — In cases of danger- ous narcosis from chloroform the aii' is to be permitted to pass freely about the patient, who should also be violenth' shaken and perhaps Nelatonized (suspended by the feet) ; water dashed into the face ; artifi- cial respiration instituted ; i)erhaps a catheter introduced into the larynx, or a tracheotomy performed ; mouth-to-mouth l)reatliiiig practiced : the phrenic nerve faradized, one pole being placed over the scaleni, low down in tlie neck, and the other at the lower costal margin ; the heart stimu- lated by means of hot cloths, and perhaps acupuncture ; inhalation of oxygen. In order to permit the free access of air, tlie pharmx is to be cleaned and the tongue drawn forward b}' means of a tongue-forceps. A lateral gag in the mouth is useful in addition. In Koenig's clinic at Giittingen, in cases of chloroform syncope, sim- ple compression of the cardiacs region is employed in place of the ordinary artificial respiration. ^laas* reports two very striking cases illustrative of this method of ti-eatment. In l)oth the respiration had ceased, the radial pulse was absent, and the pupils were Tvidely dilated. The move- ments were continued for over an liour. The compression is made by placing the foot upon the patient's left thorax and making quick move- ments of pressure over the cardiac region at the rate of one hundred and twenty times or more a minute. The right half of the chest is steadied at the same time, Dangerous Vomiting Following an Ancestbetic. — The after-vomit- ing nuiy prove a dangerous sequel to the administration of an ana^sthetic, and should receive attention at the surgeon's hands. The taste of the xin{i?stlietic increases the fiow of saliva, and as the expelled air contains more or less of the anaesthetic agent for some time afterward, the secre- tions of the mouth, loaded with this, are swallowed and, irritating the gastric muc(ms membrane, provoke intense nausea and per.sistent vomit- ing. The patient should be encouraged to eject the accunnilations in the mouth. Lavage with a one-lialf to two percent, carboiuxte-of-soda solu- tion is frequently effectual in aff(U-ding relief. The Use of Chloroform at Night.-^The use of chlorofcmn at night is to be av(^ided as much as possiT)le. It is a common experience under these circumstances to observe some peculiar effects, such as a tendency to vomit, an irritative cough ■v\dth subsequent developnient of broncliitis and severe catarrhal pneumonia. These are supposed to be due to com- l)inations between the vapor of the chloroform and the products of combustion. * Berliner KUn. Wocheuaelirift, No. 12, 1802. (500 ^ SYSTEM OF LEGAL MEDICINE. The Administration of an Anaesthetic to Pregnant Women. — The admiuistration of an antestlietic to pregnant women, for operations of convenience, or for such operations as can be readily performed without an anaesthetic, as the opening of an abscess or the extraction of a tooth, has been the subject of inquir3^ In the opinion of some authorities the production of abortion, or the induction of prematm-e labor, in this con- nection may result, even though the narcosis is of but short dui-ation ; wliile others are equally confident that the anesthetization has nothing whatever to do mth the untoward i-esult, if any such follow, but that the latter is either a coincidence, or can be more pi'operly attributed to- the operative procedure. There are many difficulties in the way of de- ciding this question, inasmuch as anaesthesia is induced under conditions where some operative procedure is to be performed, and in patients peculiarly susceptible to mental influences ; the anxieties incident to the administration of the anesthetic, as well as those arising from fear as to- the outcome of the operation, to say nothing of the fear of an interrup- tion of the normal gestation, may all combine to bring al^out an unfor- tunate result, irrespective of the effects of the anaesthetic itself. The surgeon can have no choice but to subject the patient to the risks of the anaesthetic just as he would to the other risks of the operation, where this is one of necessity and involving great suffering should its perform- ance be undertaken without an anesthetic. Unusually Prolonged Anaesthesia. — The possibility of an unusually prolonged anesthetic effect cannot be denied, especially in the case of chloroform. These cases seem to resemble those in which the extreme effects of carbon dioxide have been suffered from. They are character- ized by slow and incomplete return to consciousness and sensibility after from forty-eight hours to three days. Con\ailsions may occur. In cases of chronic alcoholism, in which paralysis and extreme nerve exhaustion contribute largely to jDrodiice the fatal result, the latter may enter in such a manner as to sunulate death from the protracted effects of cliloroform. Objections to Ether. — Ether, particularly if a pm-e article is not used, produces irritation of the mucous membrane of the respii-atory passages to an extent sufficient to cause bronchitis or catarrhal pneumonia. As has been already shown by Wunderlich's studies, its influence upon the renal organs has been greatly overestimated in the past. The inflamma- bility of the vapor of this anesthetic agent introduces an element of danger when the oj)eration is performed near an open flame, or where the thermocautery is employed in operations about the head. Occasional Similarity of Dangerous Symptoms in Chloroform and Ether Narcoses. — The causes of death from cliloroform are, to a cei'tain extent, the same as those from ether. Distinctions have been made as- to the manner in Avhich the alarming sj^mptoms enter, as well as the vital organs first affected. Wliile in general it is true that heart failure charactej'izes dangerous chloroform narcosis, and failure of the respira- tory function that from ether, jei the fact remains that in many cases patients wiU cease to breathe under chloroform while the heart is in no wise disturbed in either its force or frequency, on the one hand, while, on the other, it is not infrequently observed that patients under ether will suffer from failure of the cardiac impulse while the respiratory move- ments are but sUghtly, if at all, affected. If the person administering- srnaicAL malpractice. GUI the anaesthetic were to wait for the pallor of the surface which is sup- posed to be tlie signal of dan^^er in clilorofonn narcosis, he wcndd Ije •deceived as to the condition of the patient, for the reason that this is sel- dom observed, and is but transient when it does occur. The patient is nni(;h more likely to exhibit the appearances of carbon-dioxide in- toxication, with somewhat pronounced cyanosis, than the spnptom of paUor. In g-eneral terms, however, it may be stated that while the symptom of cyanosis is present in both cases, in so far as our present knowledge of the action of these agents goes, in chloroform narcosis this depends upon (lefieient oxygenation of the bhjod from stasis, wliile with ether it is d(;pendeiit upon true asph^'xia from respiratory obstruction or failure. That there are numerous exceptions to this rule, however, as before stated, tliere can be no question. The fact nevertheless remains that, wliile this cyanosis oecurring in the course of the administration of ether comes on gradually-, it is quite readily remedied by the free access of au* for a short time, and is not an alarming symptom unless it persists in spite of the removal of the ana?sthetic. If it becomes a pronounced sjninptom in chloroform narcosis, the patient is usually beyond hope of resuscitation. As long as the heart's action is sufficient to carry the blood-current to the important cerebral centers an extreme cyanosis is not incompatible with prompt resuscitation. No anu)unt of foi-eing of ah- into the lungs, however, can bring al)out this result if the carbon-dioxide accumulation is the result of cardiac failure. Ether the Anaesthetic of Choice. — We must be forced to the conclu- sion, in making selection of an angesthetic, that ether, where it can be employed, is the anaesthetic of choice. Since Wimderlich has shown that the innnunity from renal sequelae formerly supposed to exist in chloro- form narcosis has no foundation in fact, the last argument in favor of the employment of cldoroform in place of ether, when the latter is not positively coutraindicated — as, for instance, by actually existing pulmo- nary conditions or in intracranial operations, in which class of cases ether .seems to increase, while chloroform decreases, the cerebral congestion; and in certain operations about the mouth and face where the galvano- or thermocautery must be used or the mask freqiiently removed in the progTess of the work — falls to the ground, when statistics shoMing the unquestioned safety of this anaesthetic agent as compared with chloro- form are considered. A collection of yearly reports* of narcosis covering C2 reports, mak- ing a total of 61,520 cases, shows, after the deduction of 11,404 cases of nitrous-oxide anaesthesia, that there were 11 deaths in the remaining 50,062, or one in 4551 cases. The number of cases of amrsthesia collected during the past three years amounts to 101,800, in which number there were 52 fatal cases, or one death in 8111 cases. Of 133,729 cases of chloroform anaesthesia there were 40 deaths, or one in 2907 cases. In 14,040 cases of ether nar- cosis there was not a single death. Of mixtures of chloroform and ether there were 4118 cases, with one fatal case. Mixtures of chloroform, ether, and alcohol (BiUi-oth's) show in 3440 cases no fatahty. In 4555 cases of * Gurlt, " Beriehterstattung liber die Sammelforschung zur Xarkotisu'ungsstatis- iik," Cciitnilblattfiir Chmmjlc, No. 30, 1893. 602 ^ SYSTEM OF LEGAL MEDICIXE. broruide-of-etliyl anesthesia there occurred one death. Of 597 cases of pental anesthesia 3 were fatal. To sum u]3. therefore, it may be said that ever}" patient to whom an anaesthetic is administered takes thereby some risk, but that this risk is less in ether than in chloroform narcosis. Each possesses especial advant- ages, but those claimed for chloroform relate chiefly to convenience, while those claimed for ether relate to comparative safety. The warn- ing signals of approaching danger in ether can be recognized before the l^atieut is beyond recall ; in chloroform he is frequently already within the valley of the shadow of death before the antesthetizer is aware that anything is wi-ong. The sm-geon, therefore, who at the present day selects chloroform as the anaesthetic of choice would do well to fortify himself with facts to show that ether is contraindicated in the particu- lar case ; otherwise the accusation may be made that an unnecessary risk was assmued in emplojdng chloroform rather than ether, the patient dying from indul»ital;)le chloroform narcosis. More skill is required to produce ether narcosis than chloroform nar- cosis ; more skill is required, also, to prevent the patient fi*om d\dng from chloroform than from ether. An indifferently skillful anaesthetizer can easil}' kill a patient with chloroform, but he will not be able to anaesthe- tize pro2:)erly with ether, much less destroy the patient without some warn- ing which the operator himself would be likely to observe. "With blood before him of a healthy hue, and iho. rh3"thm of regular and full i-espirn- tions in his ears, the latter will feel safe as he proceeds in his work, if ether is used. Either of these failing,- a word of caution to the anaesthe- tizer suffices to correct the undesirable condition. But if chloroform is employed the experienced oj^erator knov/s only too well that the dark blood and absence of respiration mean that the heart has failed in its action, perhaps for several seconds or a considerable fraction of a minute, before the dark blood and failing respiration occurred, and from this time on the most vigorous efforts must be made, with the chances greatty against liim, to rescue the patient from death. Failure to Produce Ansesthesia. — Occasionally it occurs that the attempt to etherize a patient fails, and chloroform is substituted. It is more than probable that in the great majority of cases the fault lies with the anesthetizer, and not with the j)atient or the anaesthetic. In the rare instances in which, either fi'om the extraordinarily excited condition of the patient, or the occurrence of convulsive or even tetanic respu*atory movements, there is a failure to anaesthetize referable to the agent selected, it will l:)e found that the patient has been in the habit of indulging largely in alcoholic stimulants. A change to chloroform is here indicated, the ether, however, being resumed when narcosis has been established. Protection of the Patient's Face. — Complaints of negligence may be made where the antesthetizer fails to protect the jDatient's face from con- tact with the anaesthetic by the application of some unctuous material. Vaseline answers the pm*pose very well and is usually employed. Move- ments of the patient's head may lead to the accidental entrance of ether or chlorofonn into the patient's ej'es, but beyond the temporary burning sensation no harm usually results from this. It should be provided against by placing a folded towel or napkin over the eyes. SVEGJCAL MALl'UACriCE. 003 Hydrobromic ether (bromide of ethyl) Las been employed to some extent tor short operations. It would seem, however, that this aj^ent is not altogether free from danger.* From 5 to 10 grams usually suffiee for complete nareosis, altliorigh from 15 to 20 grams may be used. In one case 40 and in another -lO grams were employed with fatal results in healthy [)ersons. It is a dangerous agent to employ for long operations, profound narcosis leading to destruction of the blood-coi-- puscles, with ))]oody diarrha^a. It is particularly contraindicated in anaemic and hysterical women. In one instance of this kind 7.5 grams proved fatal. There was no cyanosis, but the respirations failed com- pletely, only two ineffectual respiratory efforts being made after narcosis was established, when death took place. In Billroth's clinic 400 anais- thetizations were made with bromide of ethyl; in one case a fatal result followed the sudden elevation of the patient to the upright position for the purposes of the dressing. In this case cyanosis was observed after some seconds. Tln-ee minutes after the esta])lishment of the narcosis both heart and i'esi)iration had failed. The post-mortem showed degen- erative changes in both the heart and renal organs. It is now generally agreed that bromide of ethyl is less dangerous than chloroform, but that wlide it possesses some advantages as to con- venience, etc. — i)atients coming out from under its influence very much as from nitrous oxide or laughing-gas — ^Tt it must be used cautiously as regards the quantity employed. The stage of excitement occurring in connection with its use corresponds closely to the amount used. -The quantity to be used in a given ease is poured upon a cone similar to that used for ether and covered with a napkin. Rental has recently been introduced as an ana?stlietic agent. Experi- ence with it has been thus far too limited to admit of any definite opinion as to its merits. The stage of excitement is said to be very short ; in alcoholics, however, it may be longer. From 10 to 20 grams are needed. The effect is said not to be unpleasant, and j^atients do not straggle against its administration as with other anesthetics. Sensil)il- ity is abolished after al)out 50 seconds, and the stage of deep analgesia is reached after from 10 to 20 seconds longer, this lasting for a further 50 seconds. The vapor of pental is easily inflannnable, and the same precautions are I'equisite in this respect as during the administration of ether. The patient conies out from under its influence slowly. Bronchial and cardiac affections contraindicate its use. A j)eculiar odor, compara- ble to that of asafetida, pervades the room after its use. Nitrous Oxide. — Probably the safest of all general anaesthetics is nitrogen monoxide, or laughing-gas. Its use is greatly restricted, how- ever, by the fact that under ordinary circumstances an anaesthetic effect of but short duration is ol)tained, although Dr. G. W. Brush, of Brooklyn, kept a patient, upon whom the writer performed a laryngectomy for car- cinoma of the larynx, under its influence for an hour and forty minutes.t Special skill, how^ever, arising from a long experience with the agent is necessary in order to successfully accomplish such a I'csult. Bert's method involves the use of a speciall}^ constructed inhalation chamber, * MiinchcH. Medic. Wochcnsvhrift, No. 15, 1890, p. 267; 1891, p. 5-4-4. t American Journal of the Medical Sciences, October, 1889. 604 ^ SYSTEM OF LEGAL MEDICIXE. and is not applicable for general nse. It would ajDpear that this chamber is not at all necessary for the purpose. Matters in Defense in Cases of Fatal Narcosis. — The dif&cnlties in the way of exactly regulating the dose, because of the fact that all gen- eral anfesthetics are exliibited in the form of gas or vapor, has not been overcome by any of the so-called safe inhalation apparatus introduced for this puipose. And even if this were not true tlie maximum dose for anaesthetic agents has not as yet been estal)lished, as in the case of other powerful drugs. The quantity to be employed in any given case, there- fore, must depend entu'ely upon the surgeon's subjective judgment. What is more than all other things necessary, therefore, is that the sur- geon must be familiar with the particular agent which he is using, and, especially in the case of chloroform, Tsith the deteriorations which this agent is subjected to when kej)t for a long time and exposed to influ- ences, such as sunlight, that tend to alter its physical qualities. For such changes occm-ring prior to the chloroform coming into the hands of the surgeon the manufactui-er or dealer is to be held responsible. He must lLk;e^\dse be familiar with and have at hand approved means of resuscitation, as well as di'ugs of an antidotal character, such as strych- nia, tinctui-e of digitalis, amyl nitrite, etc., to administer should danger thi'eaten the patient. With these conditions fulfilled, and no easily dem- onstrable conditions present to contraindieate its employment, general an- aesthesia may be established even for the performance of unimportant or shght operations. The omission to at least auscult the patient's chest beforehand would be considered culpable negligence, even when such auscultation, if employed, has demonstrated the presence of a heart mui'mui*, in a case in which it is absolutely necessaiy that the anaes- thetization be proceeded vnth. The information acquired, although per- haps it would not prevent the use of the anfesthetic, would tend to in- duce a measure of watchfulness and caution which, it might be claimed, would not otherwise be employed. Examination of the chest organs, however, does not always afford ti'ustworthy data, but this does not ex- cuse the omission of this precaution, except in the face of grave emer- gencies. On the other hand, as before stated, the indubitable evidences of existing disease, the circumstances of the case requiring the use of the anaesthetic, may permit this within proper limits, and with the usually employed restoratives at hand. It will usualh^ be sufficient for the sur- geon's protection (1) that the use of the anfesthetic was necessary; (2) that the agent employed was adapted to the particuh^r case ; (3) that a watchfid care was exercised during the administration ; (4) that the usual restoratives were at hand, and that these were intelligently applied if they were requii'ed. SPECIAL OR REGIONAL CONSIDERATIONS. In re^dewing the accidental complications and unfortunate sequelae which may occur in surgical ojDerations and affections, it is to be observed that there is scarcely any jDrocedure that may not lead, either from indi- vidual carelessness or pure accident, to misfortune. It is intended in this connection, however, to only call attention to some of the more prominent accidents in which there may be a question as to the avoida- bility or otherwise of the unfortunate termination. SURGICAL MALPRACTICE. GOo Opening an Abscess. — Even opening an abscess has been the occasion of accidentally woiindino- an inii>()]-tant vessel. Anenrisins have been mistaken for abscesses and opened with fatal resnlts fi-oni henion-liag-e. Venesection. — This operation is now rarely performed, but this very fact tends to lessen our estimate of the importance of carrying out the j^rocedure in a proper manner. The median cephalic vein, selected for the purpose, is sojuetimes perforated completely, and the adjacent artery is injured as well. The artery should be a(!curately located before placing the cojistricting band upon the arm. The surgeon recognizes the ■occurrence of this accident l)y the simultaneous steady flow of dark venous blood and the pulsating stream of bright arterial blood. If he bears in mind the fact that the remote injurious effects of this accident relate mainly to the resulting communication which is established be- tween the artery and the vein, and takes immediate steps to prevent this by occluding the artery by means of a graduated compress applied to it at a point central to the place of injury, in a large majority of cases no permanent harm will result. Embolism from Injection of Vascular Tumors, Varices, etc. — At- tempts to obliterate vasculai' tumoi's and varices l)y the injection of cer- tain substances, such as ferric chloride, carbolic acid, etc., have been fol- lowed by rapidly fatal results. Usually an elastic bandage is placed above and below the point of injection as a precautionary measure. The object of the injection is to produce an obliteration of the enlarged ves- sels by coagulating the blood. The premature removal of one of the bandages, particularly that one between the seat of coagulation and the heart, has resulted in the occurrence of coagulation in the vessels T\dthin the thorax, and rapid death. Aneurism. — Aneurism may at times present the most difficult prob- lem in the art of diagnosis. This is due to the fact that the disease is mai'ked by varying conditions and instability of symptoms, as a result of the different varieties and pai-ticular stages of each variety, as well as to the fact that the contents may be entirely fluid, semi-fluid, or nearly or quite solid. Any or all of the symptoms may be misleading and bring the surgeon into disrepute because of failure to recognize an aneurism when present, or of ndstaking another form of tumor for aneurism and instituting danger- ous measures of treatment, such as incision, ligature of the main vessel of an extremity, the application of continuous pressure, etc. For instance : •(«) every tumor situated in the course of an artery is not an aneurism ; (&) ])ulsation nuiy be absent when an aneurism is present, and expansive pulsation nuiy be present in an abscess surrounding an artery ; (c) the pulsation may cease in a tumor or swelling situated upon oi- in the neigh- t)orliood of an artery when compression is made upon the cardiac side, on the one hand, while, on the other, subsidence of the swelling may not occur and yet an aneurism be present ; {d) a bruit mny be absent in aneurism and be present in the case of an abscess or tumor surrounding or situated upon a vessel; [e) even exploratory puncture may residt in the withdrawal of bright arterial blood in several vai'ieties of tumor, and in aneurism this means may fail to give exit to blood. The history of the case is of great value, and errors in diagnosis arise most frequently from failure on the part of the surgeon to carefully in- quire into the early symptoms, the length of time of their existence, etc. 606 ^ SYSTEM OF LEGAL MEDICIXE. Under these circumstances the practitioner may be justly regarded as- ha\dng been culj^ably negligent. The most eminent surgeons, however, have failed to make a correct diagnosis, even when the history has been taken into account, the symptoms methodically studied, and the value of the latter carefully weighed in the particidar case. Many instances are recorded in which an aneurism existed when the histoiy and symptoms indicated an abscess. (Sir Charles Bell, Dupuy- tren, Cooper.*) Again, the early history may indicate an aneurism, all the symptoms pointing to the existence of an abscess. Finally, an aneurism and abscess may coexist. The former may follow and be dependent upon the latter, in which case the early history and sjonptoms point to abscess, while the later ones indicate the existence of an aneurism. Or the aneu- rism may occui- first, followed by inflammation in the connective tissue about the tumor, terminating in suppuration. (Deschamps.) Under these circumstances the early histoiy is that of aneuiism, the later symptoms those of abscess. The symptoms of aneurism, however, continue to be the more i3rominent, as a rule, and errors of diagnosis are not necessarily of a serious character, for the reason that the careful and intelligent sur- geon will always take into account the symptom of pulsation and apply such scientific tests as may serve to clear up the diagnosis. If he is finally impelled to incise the swelling he will do so with such precaution- ary measures as will permit him to either retrace his steps before great harm has been done, or operate for the cm'e of the aneurism. Puncturing an aneurism by mistake for an abscess has not infrequently occurred. These are among the most serious of the mishaps of surgical practice, and if expansive pidsation is present, they are certainly ajnong the most inexcusable. Two such cases came under the care of Mr. Erichsen, and both succumbed to the operative procedure iustituted to correct the mistakes of the practitioners who were guilty of the errors. In a third case there was some excuse for the error for the reason that the symptoms of popliteal aneurism were not weU defined. {Lancpf, 1858.) The error of mistaking an abscess for an aneurism in a locality where, if the latter existed, it woidd be almost necessarily iucui*able, while an abscess would imperatively demand operative interference, is sometimes made. The following case is offered in illustration : Miss B., of Rockville Center, L. I., aged twenty-two years, a school- teacher by occupation, was referred to me by her attending physician for diagnosis. She had noticed a tender spot over the third rib upon the left side for about two months, following which swelling occuri-ed,. and fever of an intermittent t^^pe. There had been no symptoms of car- diac disturbance, no dyspnoea, nor had the present tumor, the size of a fist, been preceded in its development by the usual extreme pains incident to the progi-ess, in an outward direction, of thoracic aneurism. Before presenting to me the letter of introduction from her physician she visited some friends in the city, who persuaded her to consult two other sur- geons. The first of these introduced an exploring needle and withdrew a small quantity of blood. She then consulted the other surgeon, who pronounced the case to be one of aneurism and strongly advised her not to permit, under any circumstances, any surgeon to intei-fere with the * Stephen Smith, American Journal of tlic Medical Sciences, April, 1873. SURGICAL MAI.m.K IK !■:. (JOJ tumor, but to i)roeeed at once to lier parents' home in western New York, there to await lier inevital)le fate. Upon examining- the tumor I found it to be the site of a well-marked but not expansive pulsation. There was no bruit present. The skin over the tumor was reddened and tender. The age of the patient, the history of the development of the tunu)r, and the accompanying feljrile symptoms all impelled me to the diagnosis of abscess, and I proposed to her to enter the Methodist Episcopal Hospital for exploration at least. So impressed was she, however, by the warning of the gentleman who had pronounced the case to be one of aneurism that she decided to go home to die. Six months later I learned from the physician who had referred her to me that the local practitioner who had her in charge at her parents' home had become convinced that she was suffering from an abscess, and had persuaded her to permit a surgeon from a neighboring city to oper- ate. More than a quart of pus was evacuated, and extensive necrosis of the chest wall discovered. No aneurism was present. Gunshot Injuries. — The greatest possible diversity will be found to exist in different cases of gunshot injuries. Differences in velocity, pro- jectile force, angle, articles perforated before the l^all reaches the body, and tissues traversed, all have an influence in determining the character of the injury. A ball may strike a bone, giance off, and bury itself into the siuTounding structures. Although the injuiy to the soft pai-ts, to- gether with its sequela', will occupy the attention of the siu'geou, the fact is not to be lost sight of that certain changes may take place in the bone itself, such, for instance, as infectious periostitis and ostitis, the infec- tion finding its way into these strnctures eithei* dii-ectly from foreign sub- stances carried in with the ball itself, or from suppurative pi'ocesses ha^'- ing their point of commencement in the soft parts aud subse(pieutly extending to the bony structures. The immediate complications most to be dreaded iu gunshot injuries relate to important vessels and nerves. While hemorrhage from vessels in the torn and lacerated muscular structures may be at first profuse, the irritability of the latter, producing involuntary muscular contrac- tions, together with the tendency on the part of the In-uised and irregu- larly divided walls of the vessels to favor coagulation, lead to i-ather prompt arrest of the bleeding. But the surgeon should not overlook the possibility of a contusion of the wall of a large vessel having occurred, which may lead in the coiu-se of a week or ten days to a most pi-of use and dangerous secondary hemorrhage. Failure to provide against the possibility of this accident may become a source of reproach to the attend- ant, or even become the basis for a suit for malpractice. More or less damage to important nerve structm-es may occtu* in gun- shot injiiries, which in the excitement of the moment maybe overlooked. Such iujuries are most frequently fouud where the extremities are in- volved, either from the direct blow of the ball, by force transmitted through the medium of a fragment of bone, or by muscuhu* contraction forcing pointed or sharp-edged spicuhi? against the nerve trunk. Injury to important nerves, when sutficiently severe, leads at once to complete paralysis of their peripheral distribution. In addition, injury to lar-ge nerves greatly increases the surgical shock, which may become so pro- found as to briuii; about fatal inhibition of vital functions. <50S ^ SYSTEM OF LEGAL MEDICINE. If a fracture has takeu place as tlie result of a gunshot injury, the bone may be completely shattered, and the residting deformity will be at once apparent. But if a portion of bone has been simply carried away by the ball in its passage, nothing short of an exploration, and this jjreferably with the surgeon's finger, properly cleansed and disinfected for the purpose, "v\dll suffice in estabhshing the diagnosis. Neglect of this in the case of a gunshot wound of an extremity, or in fact in all portions of the body, with the exception of penetrating wounds of the great cavities, may lead to error as to the extent of the injury inflicted. The surgeon's fixst investigation will be directed as to whether the missile is still located in the tissues or not. He will therefore seek to ascertain if there is present a wound of exit as well as one of entrance. Several fallacies may enter at this point, against which the surgeon must be on his guard. The existence of but one wound does not always de- termine the Cjuestion affii'matively, any more than the presence of two wounds can decide it negatively. In the first instance the ball may have di'opped out in transporting the patient, or may have been di'agged out in undi'essing the patient by a portion of clothing which was carried into the wound with the baU. An accurate inspection of the surroundings, including the clothing of the patient, should therefore be made, in order that needless injury be not inflicted in an unnecessary probing of the woimd in searching for the ball. Failing to thus find the ball, attention should be directed to the possibility of the baU being superficially located. To this end every portion of the adjacent and even remote parts which <^ould have possibly been in the line of the projectile is to be carefully examined. Next, the possibility of the ball having been deviated from its coiu'se by contact \\dth bone or by dense planes of intermuscular apo- neurotic structures after its force was partially spent should be taken into account. Carefiil palpation should be performed, in order to be certain that the missile does not lie directly beneath the skin at some point easily accessible for piu'poses of removal, before instituting a formal and perhaps dangerous exploration or extensive dissection for its removal. All suspicious elevations of the skin should be carefully examined by the surgeon, and failing to thus locate the bullet the question as to whether fmther search should be instituted or not should be discussed. In eases in which two wounds exist, one representing the point of entry and the other that at which the ball left the body, there may still exist a doubt as to the absence or presence of the missile, or at least a portion thereof, in the tissues. The wisdom of examining the clothing is here again manifest. A ball may have been split or divided \>y contact with a sharp bony edge, and in its fmther passage a portion may have left the body by the wound of exit, while the rest still remained lodged in the tissues. The portion which escaped may sometimes be found in the clothing, and, its di\dded condition being apparent, form the basis for further search. The justifiability of risking injury to important parts in attempting to remove the ball, after having located the latter, should be decided only with reference to the patient's own interests. The dangers to be feared from its presence in the tissues should be weighed against the risks at- tending its removal. It is a grave error to mutilate a limb or to invade one of the gi'eat ca^nties of the body in the search for or removal of a ball whose presence would, in all probability, do less harm than the operative procediu-e itself. Wliere, however, as for instance in the peri- SURGICAL MALPRACTICE. GOD toneal cavity, serious complications may arise — not necessarily from the continued presence of the ball, but rather from damage done to impor- tant structui'es by the es(uipe of fecal matter from the intestinal canal, liemorrluige, etc. — explorative operative procedures are not only war- ranted but imperatively demanded. Under these circumstances merely tentative measiu'es such as probing are not only contraindicated, but are apt to do more harm than good. The passage of a probe cannot give trustworthy information as to whether intestine has been wounded or hemorrhage is going on in the alidominal cavity, any more than it can determine the probiible course of the ball beyond its passage through the abdominal parietes. On the other hand, probing may carry infec- tion Jinto the peritoneal cavity, or, if it chance to pass into a perforation of intestine, may, in withdramng, smear fecal matter ui)on the peritoneal sui'faces. In grmshot wounds of the head meddlesome surgery is always bad surgery. While tui'uing back a flap of the scalp in order to determine whether or not the ball has entered the cavity of the skull, and the inci- dental removal of accessible spiculte of bone which have been driven into the cerebral tissues, are proper procedures in selected cases, failure to institute further interference than this mil never bring reproach to the surgeon. Under these cii'cumstances his conservatism will be com- mended by his professional brethren. Aimless probing, on the other hand, will be almost certain to inflict further damage. THE HEAD AXD NECK. Atheroma of the Scalp. — These so-called ''wens" are frequently re- garded as simple affairs, and operated upon by those who have had but slight experience in surgical operative work. While the operation is usually a simple one, this very fact sometimes leads to a neglect of precautions which would be taken in more serious operations. In pre- antiseptic times many of these cases perished fi'oni erysipelatous inflam- mation, to which the region of the face and scalp seems to be especially prone. Patients, especially women, mil frequently object to the removal of the hair necessar}^ to a complete aseptic course of technique, and the surgeon wiU be inclined to listen to their entreaties. If the practitioner has a due regard for the patient's best interests as well as for his own reputation he Avill insist upon the necessary steps of preparation, or de- cline the responsibility of the operation. Trephining. — This operation has not infrequently been performed with the expectation of finding an abscess of the brain, oi- a coagulum, when neither was finind. Exploratory trephining in cases diagnosticated as hemorrhage from the middle meningeal artery is followed, even in the best of hands, by the discovery that the blood is fm*nished, not by the artery, but hj one of the sinuses of the dura nmter. Operations for Harelip. — Few realize the intrinsic dangers of the operative procedure for the correction of this congenital deformity. It is estimated that fully one third of the cases submitted to the operation die (Nussbaum), as an immediate result from suifocation consequent u])ou the enforced closure of the mouth. Following the loss of considerable blood, the little patients easily succumb to slight causes. The infec- 610 ^ SYSTEM OF LEGAL 2IEDICIXE. tion of a sutiu'e track, due to the negiect of asejDtie precautions, leads to eiysipelatous inflammation, wliich. in its turn produces pain and rest- lessness. Fear of failure of the operation leads to the administration of opium, which the little patients bear badlv in their weakened condition. Without the administration of opium the continued acts of crpng- lead to straining uijon and finally the tearing out of the sutui'es. The deformity is thus frecpiently made worse than at first. The cosmetic result in cases of hareHp is frequently unfavorable even after the best-conducted antisej^tic procedui'es, for the i-eason that the operator does not fully appreciate the necessity of a decided projection upon the vermilion border at the point where the incision terminates, to allow for subsequent contraction of the cicatrix when perfectly healed. This contraction may go on for a long time, and unless the precaution alluded to is observed an unsightly notch will appear at the point where, at first, the Up was perfecth' sjTnmetrical. A fiu'ther unsighthness fol- lowing the operation results from the injudicious removal of the promi- nent intermaxillary bone. A comparison of the faces of two persons operated u]Don in early life for harelip, in one of whom the intermaxillary bone was removed, while in the other it was allowed to remain, shows such striking differences as to stamp the former procedm-e as most unjus- tifiable and cruel. The selection of the proper age for the operation is of importance. While single harelip may be oj)erated upon at ahnost any time, in double hareHp it is better to po.stpone the operation until the second year of life. Cleft Palate. — In cleft-palate operations the same dangers threaten the child as in harelip, Imt to a gTeater degree. Very young childi-en do not bear the loss of blood at all well, and therefore it is better to defer interference until they arrive at an age when they can undergo the neces- sarily extensive operative procedures with less fear of an immediately fatal result. The mortahty in early infancy is almost fifty percent. The most favorable period for the operation so far as danger to life is con- cerned is at the fifth year. (Sehede.) On account of the extent to which ui-anoplasty interferes with the development of the arch of the palate, it may be postponed until the period of the second dentition, or between the tenth and twelfth years. (Ehrinann.) Failm'e in the immediate result is less frequently due to an insuffi- ciency of blood-suj)ply from injmy to the arterial branches than to the fact that too few veins are present in the pedicles to maintain the return- circulation. The cicatricial tissue left, however, after the mucoperios- teal flaj^s have sloughed away, can frequently be utilized for a second operation. Failure in the functional result is more frequent and important. The voice is not greatty, if at all, improved, and the surgeon is frequently blamed because of the disappointment in this respect by both the patient, when old enough to realize the extent of his misfortune, and l)y the fiiends. In undertaking an operation of this kind the siu'geon should bear in mind that a congenital cleft in the palate is not merely a .slit in the parts, but that an actual deficiency of tissue exists. Hence even after a most skillfully performed operation for closure of the cleft the velum still remains as a tight curtain stretched across between the oral and pharyngeal caAT.ties and the posterior nares, which is too short to reach the posterior pharpigeal wall, and past which the air rushes SURGICAL MALPRACTICE. Gil from the pliaiynx thrmig-h the posterior nares ; the peculiar nasal twang is, therefore, still present. Wliile certain vocal exercises are not with- out value in obviating* this, a perfect production of normal voice and speech has probal)!}^ nev'er l)eeii produced by lu'anoplasty and staph}-lor- rhaphy. The Teeth. — The accidt^ntal extraction of the wrong tooth has some- times brought reproach upon the operator. This occurs moi-e fre(|uently since the inti-oduction of iUUTesthetics. The patient will not always be able to point out the tooth which is at faidt, and even if al)le to identifj^ it he may place his finger upon two or even three in the attempt to indicate the one which causes the difficulty. Again, two teeth maj'' be so closel}- attached as to make it impossilde to remove one without the other. Luxa- tion of the lower jaw has occurred when great force has been necessary in the extraction. Fracture of the jaw, coiisideraljle portions of the alveolar process being brought away with the tooth, has been the basis of malpractice suits. Such accidents will occur in the most skillful hands, but if the mouth be carefully kept clean and septic complications avoided, the patient can scarcely have been sufficiently damaged to warrant a suit. While replacing the broken-off part may sometimes he folk) wed by com- plete union, yet the pressure of a loose and perhaps pointed or sharp- edged piece of bone in the oral cavity invites dangers from irritation of the adjoining cheek and tongue which far outweigh any advantages to be derived from the replacement and union of the bone itself. Hemoi'rhage following the extraction may be alarming, and requii'e the employment of the thermocautery for its arrest. When dentures are attached to the patient's own teeth the latter may become worn at the point where the metal clasps are applied, with the result of allowing the plate and artificial teeth to fall back into the pharynx or esophagus. Cases are recorded (Nussbaum) in which a dent- ure has been lodged in these positions for months without giving rise to dangerous consequences. Under these cu-cumstances, for the reason that the treatment of a condition shoidd not be more dangerous than the condition itself, surgeons have generally not ad\"ised interference before some du*ect indication had existed for this. Tonsilotomy. — Several accidents may follow this apparently simple operation, for which the surgeon may be blamed. The shce of tonsil removed has fallen upon the glottic opening and caused suffocation. With the modern tonsil guillotine the risks of this accident are reduced to a minimum. The instrument also guards against injury of the larger vessels, which may occur when an ordinary scalpel is used. The presence of a calculus in the tonsil may prevent the use of the guillotine, and even break it, and necessitate the use of the scalpel or bistoury to dis- entangle the broken instrument, as well as to remove the tonsil. The surgeon may be compelled to adopt the use of the scalpel by force of circumstances. Hemorrhage following the operation of tonsilotomy has given rise to great anxiety, as regards both the patient and the surgeon's reputation. Wliile ligature of the external carotid artery has been re- sorted to in this complication, the necessity for tliis nuist be exceptional. The application of the thermocautery or pui'e spirits of turpentine is fre- quently sufficient. These fading, suturing together of the pillars of the fauces over the bleeding stump of the tonsil will almost certainly arrest the hemorrhage. (312 J. STSTE^I OF LEGAL MEDICINE. Retropharyngeal Tumors. — lu the osteoplastic resection of tlie upper jaw suggested by Laugeubeck for the removal of retrophaiyugeal tumors, portions of the growth mav become detached from the remainder and fall upon the glottic opening, prodncing death by suffocation. Catheterization of the Eustachian Tube. — Fatal phlegmon of the neck has followed attempts at catheterization and mflation of the Eusta- chian tube, the au' being forced into the cellular tissue of the neck. Mastoid Disease. — In cases of suppnrative disease of the middle ear the surgeon who fails to take note of the supervention of mastoid dis- ease, when such well-marked e^ddences of this condition are present as- are furnished b}' the occiu-rence of swelling and tenderness over the mas- toid region, commits a serious error. The occurrence of gastric irrita- tion in these cases should also arouse snspieion. The proximity of the cerebrum to the labpinth, only a thin lamella of bone intervening, and the dangers of infection of the cerebellum throngh pldebitis of the lateral sinus, should be borne in mind. It is not a serions mistake to ti'ephine the mastoid process and not find pus ; but it is a most gTave error to fail to apply such a comparatively simple procedure in cases in which the patient's life depends npon its performance. Injury of the lateral sinns is a not infreqnent accident in trephining the mastoid process. An exceedingly threatening or even fatal hemor- rhage may follow. In performing this operation the sui'geon should bear in mind the importance of not carrying the perforation of the bone,, or the clearing out of the abscess ca^-ity by means of the sharp spoon,, too gTcat a distance fi'om the immediate neighborhood of the helix. Tracheotomy. — Several accidents may occm- in the com-se of a trache- otomy. There may be an alarming hemorrhage fi*om the engorged ves- sels in the neck. The o^^ening of the trachea, particularly if the case is an nrgent one, need not be delayed until this has been arrested. The application of a few hemostatic forceps, and relief of the dyspnoea by the introduction of the cannula, will be almost always followed by an im- provement. The trachea may elude the operator and the esophagus be wounded,. or the latter may occur from transfixion of the trachea, a tracheo-eso- phageal fistula becoming established. Or the trachea may be opened upon its antero-lateral or even its lateral snrface, great difficult}^ being- experienced in the introduction of the cannnla. These difficulties and accidents may nsually be avoided by inserting- a tenaculum into the trachea and steadying the latter while the incision into the anterior wall is deliberately made. The hold which the tenacu- lum has upon the trachea should not lie rehnquished until the cannula is in position and all hemorrhage arrested. In the absence of the surgeon a j)iece of false membrane may become loosened and block np the cannula. Those left in charge of the patient must be instructed under these circumstances to remove the cannula entirely, rather than i-isk the delay incident to efforts at clearing its lumen. If the loosened piece is engaged in the tube it will probably come out with it; if not, the opening in the trachea affords a larger exit than the lumen of the cannula. Thyroidectomy. — In addition to the dangers of the operative pro- cedm-e itself — invohing as it does extensive dissections in the neighbor- hood of important vessels and nerves, during which accidental injuiy to SilidlCAL MAIJ'RACTWE. G13 tlieye may result in destruction of the patient — and those arising from sudden bendinLlity of this complication. Deformity Following Fracture. — One of the most damaging sequelfe (to the surgeon's reputation, at least) of fractures is the occurrence of deformity following the uni(m of a fractiu-e, and the existence of short- ening as compared ^vith the opposite limb. A palpable bend or bow in an extremity is a constant reproach to the surgeon's art, sometimes un- avoidable, it is time, so far as the siu-geon is concerned, but, alas ! too frequently the result of failure on his part to bear in mind the golden Si'ltaWAL MALriiACTWE. G13 rule never to permit the first dressing to remain during the entire process of repair, but to remove this at least on(!e, and i)erhaps oftener, and that at a period of time suflieiently early to permit of correction of any exist- ing malposition. Inspection of the injiu-ed parts at the " half -healing point " will save many crooked limbs, as well as regrets on the j)art of the surgeon, since even then the union is so soft as to permit of neces- sary correction of position. Fracture of the Neck of the Humerus. — The mistake of diagnosing a fracture of the neck of the humerus as a dislocation is not infrequently made. The differential diagnosis is not always easily made, particularly where consideral)le swelling exists. The careful surgeon, in case of doubt, will prefer to d<'lay his attempt at reduction until after the swell- ing has subsided, rather than risk the infliction of further damage by his manipulations. The combination of a fracture of the neck of the humerus and a dis- location is sometimes observed. Even when this complicated condition is diagnosticated the surgeon is at a loss to decide upon the proper meth- ods of procedure. If he delays interference until complete solidification at the seat of the fracture is effected, the difficulties of reducing the dis- location are greatly increased over those encountered in uncomplicated dislocations. The method of McBurney, of exposing the head of the bone, driUing the latter, and inserting a traction-hook by means of which the displaced portion is replaced by directly applied force, probably offers the patient the very best chance of a useful arm. Injury to the Circumflex Nerve Simulating Dislocation of the Shoulder. — The course which this nerve takes around the neck of the humerus, as well as its relations to the shoulder-joint, render it especially liable to injury from blows or falls upon the shoulder. Dislocations of the humerus are also occasionally followed by paralysis in the course of the distribution of the nerve. In chronic inflammatory conditions in the shoulder- joint the nerve may become involved in a neuritic process. As a result of interference with the supply of the circumflex nerve there is a noticeable wasting of the structures which clothe the joint ; and suits for malpractice, based upon these appearances and a failure on the part of tlie surgeon to discover and reduce a supposed dislocation of the shoulder, have resulted. With extreme atrophy of the deltoid muscle there is a marked prominence at the acromion process and a decided groove per- ceptible through the atrophied muscle between the head of the humerus and tlie articular surface of the scapula. Under these circumstances the resemblance to a dislocation is striking, until manipulation discloses the real condition. Fractures near the EIbow=joint. — Fractures in the neighborhood ■of or involving the elbow- joint are apt to give rise to contractures and anchylosis in this articulation, from inflammatory conditions the resiilt of the injury. While these are frequently unavoidable, and no one may know beforehand in the individual case to what extent these may imjiair the usefulness of the arm, the extent of the loss of function, when it does occur, will depend, in great measure, on the care which the surgeon exer- cises in placing the member under conditions in which, should anchylosis follow, the patient may be able to perform certain needful movements. An arm anchylosed in the straight position, or nearly s(\ will be practi- cally useless, and one sharph' flexed will be nearly so. With the forearm 616 ^ SYSTEM OF LEGAL MEDIC IXE. at right angles to tlie arm, a compensatory increase of the range of mo- tion at the shoulder occurs, and the patient will be able to execute move- ments ^dth the extremity to a siu'prising extent. While the treatment of a fractui-e of the arm in this locahty in the straight or extended position (anchylosis not occiUTing) gives a more sjanmetrically perfect arm, for the reason that the normal angle which the radius and ulna bear to the hiunerus is preserved and with it the so- called carr}dng function, yet, as before stated, no one may know before- hand whether or not the inflammatory changes will be such as to j)revent fi'ee motion at the elbow- joint. Hence, in order to prevent this undesir- able complication, the surgeon will do well to carefully study each case,, and endeavor, in the event of the probabilit}^ of anchylosis, as e^dnced by the presence of severe injury to the joint and extensive extravasation in the soft parts, to obtain early passive movements. The arm is to be retained at a right angle to the forearm in the intervals, if these move- ments produce increase in the inflammatory conditions to the extent to- indicate their discontinuance. In other words, although rest is indicated when the inflammatory process is intra-articular in its location, motion is indicated if the inflammation is extra-articular. If the inflammation be both intra- and extra-articular, in order to meet the fii'st-named, rest is indicated ; but this prolonged to the period sometimes necessary to bring about complete restoration of the joint will lead to contracture of the muscular and tendinous structures and restriction of motion; at the same time adhesions will form within the joint itself. It would seem that compromise measures, consisting of fixation of the joint at a right angle in the intervals by means of a sphnt, and the application of massage, serve best in these cases. It is also to be noted that after the intra-articular inflammation has subsided and some range of movement is accomplished, this is generally increased by the patient's- own voluntary movements. This is particularly true in the case of young- children. The surgeon may remove the bandages and splints at the end of a week or ten days from the date of the injury, and practice massage him- self. The application of this valuable therapeutic measm-e should not be intrusted to a lay person, or even a professional massem-, at this time, for the reason that an intelligent reapphcation of the splint and band- ages follomng the massage is necessary. Later on, when consolidation has progressed sufiiciently far and improvement in the intra-articular in- flammation will warrant it, passive movements are to be added. Should the latter increase the inflammatory action, they must be abandoned for the time being. All this requires the personal supervision of the sur- geon, and failure to give this to the case may bring him reproach. He caimot be held responsible for anchylosis resulting fi-om ^'icious callus. Fractures at the Lower End of the Radius. — Impairment of func- tion following fractm^es at the lower end of the radius results (1) from failure to properly disentangle the small portion of l3one torn off by for- cible extension of the hand, and which occurs because of the toiigh and unyielding character of the anterior radiocarpal ligament, or (2) the swelling and congestion consequent upon the injury inflicted upon the surrounding soft parts ma}' pass from the stage of active hj-peraemia to inflammation, and this, invohdng the adjoining muscular aponeuroses and tendinous sheaths, produce fixation of these. This is particularly SURGICAL MALPRACTICE. G17 true if a splint apparatus that extends from the upper portion of the forearm to the finger-tips is emphjyed and permitted to remain undis- turbed during the entire period of repair. In the nuijority of eases very sKght if any retentive apparatus \\i\\ l)e necessary from the first. The surgeon who omits to apply any apparatus whatever will be less frequently reproached than he who applies a fixation splint and removes it after the end of three or four weeks for tlie first time. In the first instance the normal m()%'ements of the wrist and finger joints are more (piickly restored, and inflammatory adhesions are not so apt to bind down muscular and tendinous sti-uctures. In the second the parts are held rigidly in a position to favor coutra('ture of the niuscles and tendons as well as the occurrence of fibrous adhesions within and upon the sheaths of the latter. Where the use of a sinix)le roller-bandage does not suffice for sup- port, a splint wliich si i all hold the hand in the position of slight palmar flexion may be used. But whether the hand and forearm be enveh)ped in a simple roller bandage or supported upou a splint, the important point in the treatment is to avoid the impairment of function due to fix- ation of the tendons and to adhesions within the joints. The means best calculated to accomplish this is by the early and persistent use of daily massage and passive movements. As in the case of the elbow- joint, the surgeon should perform these for the first three weeks himself, at the end of Avliich time he may intrust them to a professional masseur. Gangrene of the Hand Following Fracture of the Radius. — Espe- cial care should be exercised in the appheatiou of a plaster-of-Paris l:)and- age to the forearm in fractures of this part which result from direct or indirect force. Surgeons, as a rule, avoid, as far as possible,. such appli- cation, on account of the liability of the occm-rence of rapid swelling and the danger of gangrene. The occurrence of blood stasis, as evinced l>y the failure of the blood to refill the vessels beneath the finger-nails promptly after it has been forced out by pressure, is an early and infal- lible test. The uad remains white ; even if the color eventually returns, if it is delayed beyond a few seconds the surgeon will do well to take note of any complaints of pain on the part of the patient, and be pre- pared at short notice to remove the baudages. Slalposition of the fragments in fi-acture of the radius may produce gangrene of the hand where no bandage whatever has been applied, through pressiu'e upon the blood-vessels. Changes in the walls of the bh)od-vessels may lead to thrombostasis, this extending to the capillary area. Gangrene Following Fracture of a Lower Extremity. — This is an extremely unfortunate com})lication. With the rare exception of the <5ases in wliich the gangrene results from simultaneous contusion of the blood-vessels or pressure from displaced fragments, gangrene of a lower extremity, the site of a simple fractm-e, is due, in this class of eases, to the too early application of a fixed dressing, such as plaster-of-Paris, sili- cate of soda, or starch. It may also arise from the application of an or- dinary splint. The occuri-ence of pain, with appeals on the part of the patient to remove the bandages, if unheeded, may lead to the most dis- astrous consequences. Under such circumstances the surgeon will be Iield responsible for the loss of the limb, which is the imn-ital)le result. The fact should never be lost sight of that the failure to apply any 618 A SYSTEM OF LEGAL MEDICINE. sort of apparatus for the first ten days, save a pillow support, can never result in harm to the injured member. At the end of this time the swelling, wiiich is the cause of the mischief, will have reached its maxi- mum. Correction of malposition, and the application of fixed di'essing or retentive apparatus, may now be employed. In about ten days from this time whatever sweUing still remains will have subsided, and the (h-ess- ings may be removed and applied. Tliis will also aiford an opportunity to inspect the parts and correct any undesirable conditions winch may be present. These remarks are particularly applicable to fractm-es wliich are the result of direct force.* Injuries to the Hip=joint. — This articulation is deeply placed, sur- rounded by large masses of muscular tissue, and is capable normally of a great variety of movements. In the young both the aponeurotic and ligamentous structures in and about the joint yield considerably, while the bony structures are in a condition to withstand considerable force before giving way. Later in life the fibrous structures become tough and unyielding, while the bone, owing to rarefying processes, is more or less brittle and. easily broken. Hence it follows that in early and middle life dislocations oceui' most frequently, while in the later years of life fractures occur* more commonly. The points in the differential diagnosis of these two great classes of injury are easily made out in t3q3ical cases. Hence the error of mistak- ing a dislocation for a fracture, and rice versa, is not frequently made. In a given case of iujnry to the hip-joint, however, in which the existence of a dislocation can be taken out of the consideration, there may still be an absence of the usual signs of fracture, and the surgeon be led into error. This arises fi'om the fact that a large proportion of cases occiu- from falls upon the trochanter, the effect of which is to force the distal into the proximal fragment, with consequent impaction. Under these circumstances the characteristic shortening and preternatural mobility ■vvdll be absent. Crepitus "^tH likewise be absent, although this symptcnn is of less value in the diagnosis of fractures in general, and particularly those in the neighborhood of the hij)-joint, than is generally supposed. It cannot be obtained when impaction is present, and any attempt to elicit it by manipulation may result in breaking loose the impaction and producing a worse condition than previously existed. The occurrence of impaction will depend to some extent upon the location of the hue of fracture. This will most frecjuently be present when the bone gives way at the base of the neck, and this variety is the most common. It corresponds to the extracapsular fractures of the older wi'iters. Impaction is rarely present in those fractures which cross the narrow part of the neck either transversely or obliquely, and which, in the main, are within the capsule. An injury to the hip- joint in which there is loss of function, as shown by inability on the part of the patient to raise the limb from the level of the body while lying upon the back, slight shortening, and e version of the foot which cannot be converted into a complete inversion, in the gi'eat majorit}^ of cases is an impacted fi'acture of the base of the neck of the femur. If the patient is past middle life and a woman the chances are still greater of this condition being present. * Nussbaum, Aerztl. Central Anzeifjcr, 1887, No. 18. SURGICAL MALrRACTICE. (J] (J The oversion of tlie limb present in impaeted fraeture of tlie base of the neek is usually comparatively slight, while that present in non-im- pacted fraeture is greater. This is also true of the shortening. The en- tanglement of the fractured surfaces \\'iU limit the shortening, while the fact that the posterior surface of the neck is im2)acted to a greater extent than in front accounts for the partial l)ut quite constant eversion, as well as the difficulty in overcoming the latter. Therefore slight shortening (less than an inch), combined with slight or only partial eversion, should awaken sus})icion of this injury, and nianii)ulation should Ije very care- fully made. On the other hand, the presence of considerable shorten- ing, together with decided or complete eversion, Avill suggest a fracture of the smaller portion of the neck of the femur. These two points, namely^ the amount of shortening and the extent of the eversion, should be ascer- tained before manipulation of the limb for diagnostic jDrnposes is made. Failure of union in fracture of the neck of the femur will occiu- in a certain proportion of cases. This is more lilvely to Ije jjresent in cases in Avhicli the fracture is at the narrow portion of the neck (intracapsular)^ for the reason that the nutrition of the proximal fragment is generally so interfered mth as to prevent repair. In some instances the peri- osteum is not torn completely across and nnion follows. In fi-actures at the base of the neck (extracapsular) non-nnion may follow from those causes which produce the same conditions elsewhere, namely, f ailiu"e to seciu-e or maintain proper apposition of the l)roken surfaces, rarefying processes either pi-eceding or following the injury, or arrest of the evolu- tion of the callns l3efore it has entered iipon the stage of ossification. Fi-acture of the neck of the femur has occm-red dm-ing attempts at reduction of a dislocation. Tliis is an nnfortnnate accident, inasmuch as it renders reduction practically impossible, and if intracapsidar, is likely to be followed by necrosis of the head, for the reason that, the liga- mentnm teres being separated by the dislocation, the nutrition of bone at this point is destroyed. Hip Disease in Children. — The importance of an early diagnosis of morbus coxarius can scarcely be overestimated. There are several con- ditions which may simulate this disease more or less closely, and which it behooves the surgeon to keep before him in examining cases in which the symptoms point to disease of the coxofemoral articulation. In the first place, it is not an infrequent experience in the metropolis to have children suffering from hip disease brought to the sm-geon's of- fice with a knee-joint painted with tincture of iodine or marked by the I)eculiar discoloration following a blister, in which the diseased condition realh' exists in the hip-joint. The patient's complaints refer the pain to the region of the inside of the thigh just above the knee-joint, or even at the knee-joint itself. The explanation of this is furnished bj' the inti- mate relations and anastomoses of the sciatic, obturator, and anterior crural nerves. An injury of the hip-joint in a child may give rise to synovitis 's\-itliout necessarily being followed by true hip disease. While it is desira))le to make a proper diagnosis whenever possible, the error indicated is of but minor importance compared to some others that will be mentioned, pro- vided the synovitis is treated properly, for the reason that this will in- volve rest, counter-irritation, and the other measures applicable to hip disease in its earliest stae:e. 620 ^ SYSTEM OF LEGAL MEDICINE. Congenital dislocation of the liip is a more commou condition than is usually considered, and may be mistaken by a careless observer for liip- joint disease. During the year ending September, 1891, twenty-five cases were presented at the New York Hospital for Ruptured and Crippled, or more than one for every ten cases of tubercular disease of the hip. A care- ful inquiiy will usually elicit the fact that the child limped from the time that it began to walk, and examination will disclose the following ob- jective symptoms : (1) a peculiar waddling gait in connection with the limp ; (2) a shortening of a half -inch oi' more ; (3) elevation of the tro- chanter (in fat children this is not always easily defined) ; (4) the limited motion is mechanical, and arises from the relations of the head of the femur to the rim of the aeetabulnni, and is not due to muscular spasm .as in hip disease. In addition there will be absence of tenderness. Children with hip disease are not infrequently treated for rheumatism. The careful practitioner will not fail to suspect the true nature of the affection at hand if he will but bear in mind that monarticular rheuma- tism in children is a very rare disease, and that the invasion of the latter is less insidious, the tenderness and pain are greater, and motion much more limited from the commencement, than in true hip disease. Surgical should replace purely medical treatment in a very few days, if decided improvement does not prompt^ follow the latter. Inflamed inguinal glands, due either to tubercular infection or the ac- cumulation of subpreputial secretions, may cause a limp and limitation of the movements of the joint. The error of mistaking this for hip dis- ease is not a very serious one from the medico-legal standpoint, and should not continue longer than necessary to make a local exami- nation. Limitation of the movements of extension and consequent limp may be early symptoms in osteitis or Fotfs disease in the lumbar region, and lead the surgeon into error. Every endeavor should be made to recog- nize and treat Pott's disease of the spine early in the affection, for the reason that if this be deferred until a protuberance appears, the disease will be well advanced, with no possible hope of overcoming the existing deformity, to say nothing of the dangers arising from the destructive bone-lesion. Save in those instances in which rest in the recumbent position is employed, as advocated by some surgeons in the treatment of early hip disease, the mistake of treating a case of low Pott's disease for hip disease would be a serious one, and hkely to delay the proper treatment until either deformity or tubercular ahscess, or both, compli- cate the case. If flexion, which is normal, be first employed in order to completely relax the psoas muscle, all other movements of the hip-joint will be found to be easily performed. Iriitation of the psoas by any diseased condition of the lumbar vertebra will cause rigidity of this region instead of increased flexibility, as found upon attempts to produce com- plete extension of the thigh in hip disease.* Resection of the Knee. — After exposure of the joint surfaces the popliteal artery may be wounded either while the siu'geon is in the act of dividing the crucial ligaments or while remo\dng the articular surfaces. The occurrence of this accident is most unfortunate, for the reason that, following as it does the division of the freely anastomosing articidar ar- * Dr. Walter C. Wood, Brool-hjn Medical Jnuniah July, 1894. SURGICAL MALPBACTICE. G21 teries, the only cliannc4 of .sni)])ly to the leg is destroyed, and amputation is the only resource left in ortk-r to save the patient. In resection of the knee-joint the operator should bear in mind the ueeessitj^ of sparing the epiphysis wlienever possible. In case of injury to this important structure, particularly in growing ehildi'en, the limb becomes relatively shorter on account of the diminished rate of gi-owth as compared with that of the opposite limb. Tenotomies and Myotomies. — These have been the occasion of gi^ave accidents. The (h'<'p peroneal nerve has been injured in tenotomy of the biceps femoris, and hemorrhage from the postei'ior tibial artery is a not infrequent accident ocled syringe should be used. This may be partially filled "with the solution to be injected, and introduced to the desired extent. The piston may be slightly withdrawn, when examination of the contents, of tlie l)arrel will discover if a flow of blood has ru.shed into the syringe to fill the vacuum. Or the ()i)ei-ator may pause for a full minute after introducing the needle, to sec if there is a marked flow of blood along- side the syringe-point indicating that a vein has been wounded, l^efore niakiug the injection. Disturbances of Function Following Operations about the Lower Bowel and Anus. — These disturl)auces may consist in either inconti- nence of fivces and gas from inability to contract the sphincter, or in the presence of a sti'ictnre. The action of the sphincter may be entirely lost from multiple incis- ions across its substance in fistula ojjerations, or from failure of the reparative process in tuberculous patients where but a single incision has been made. The process of stretching the sphincter, employed as a preliminary step in operations for the removal of hemorrhoidal tumors, may also be followed by degenerative changes and a more or less per- manent weakening of the muscle. In addition to the stretching the sur- geon may do still further damage by including portions of the nuiscular structure in the clamp or ligature, or by dissecting it away in the opera- tion known as Whitehead's, or some of its modifications. Stricture of the rectum may result from a too free application of the cautery in the clamp and cautery operation for the removal of hemor- rhoids. In both this and the ligature operation the surgeon shoidd be carefid to leave well-defined areas of mucous membrane between the portions subjected to cauterization or included in the ligature. In the Whitehead operation, in which the attempt is made to excise the entire so-called pile-l)earing area of the rectum, failure of union if the operation is not properly performed, as well as too great an encroachment upon the cutaneous surface of the anus, will residt in stricture of the rectum. Ventral Hernia. — Large wounds of the abdominal wall, whether op- erative or otherwise, are very liable to become subsequently the seat of a ventral hernia, and reflect upon the care and skill of the surgeon. In the prevention of this distressing condition it is necessary to obtain primary union of all of the di^dded structures, the different layers being united either by buried sutures, or some form of suture that will accom- plish the same result and still be capable of removal.* When the latter is employed it should be allowed to remain in situ for at least three weeks. A\niatever method is used the patient should not leave the re- cumlient position for four weeks at the earliest, some form of external bandage to support the weakened abdomiual wall should be worn, and the patient cautioned not to engage in anj- \dolent exercise for several months. THE GENITO-UEINARY ORGANS. In no one of the regions of the body occur so many surgical mis- haps or complications, and unfortunate sequelae to injuries and opera- tions, as in the genito-iuinary system of the male. Almost any accidental * See article on the "crossed suture," by the writer, in the Annals of Surgery, vol. XV., p. 351. 626 ^ SYSTEM OF LEGAL MEDICINE.' in jury or operative procedm-e is accompanied hj accidents, both avoid- al)le and nnavoidable, and the careful practitioner who has much to do with the surgery of these parts must necessarily be constantly watchful, lest his patient's life and his own reiDutation are lost at one and the same time. Catheterization. — The failure to thoroughly disinfect a catheter be- fore usiug it is a most inexcusable error, and can only be committed by an ignorant or criminally careless siu'geon. Tlie contention of the great French surgeon Civiale, remarkable from the fact that it was made long before the introduction of antiseptics, that no person ever suffered from ■catarrhal cystitis in whose bladder a foreign body had not been intro- duced, should be well considered in this connection. The making of a false passage by the unskillful or forcible use of a metal catheter or sound, in the presence of strictui'es or enlarged pros- tate, is one of the most common as well as most culpable mistakes in sm-gery. Even when the prostate has been safely reached an attemj)t to bore through the enlarged middle lobe is sometimes made, and profuse hemoiThage, and eventually abscess, is the resiilt. The yoimg and inexperienced surgeon will sometimes fail in a case of retention to empty the bladder because the instrument employed was blocked ujd ^ly a di'ied blood-clot or some debris resulting fi'om its last jjrevious use, Doubt then arises in the mind of the operator as to, fli'st, whether or not the instrument is in the bladder at all, and secondly, whether the bladder contains any mine. To guard against the possi- bility of such mistakes the catheter should be thorouglily cleansed and cleared, and the suprapubic region j)ercussed prior to the attempted catheterization. In paral}'tic cases the uriue will sometimes refuse to flow, and in atony of the bladder walls from prolonged distention the same eif ect will be observed. Under these circumstances the doubt as to whether or not the catheter has been properly passed will be cleared up b}^ making pressure mth the hand over the region of the bladder. Warnings against the use of cheap rubber catheters cannot be too often repeated. Again and again calculi ha^^e been removed from the bladder ha^dng as nuclei pieces of a broken-off catheter. Even a whole soft rubber catheter has been found in the bladder, which had slipped in when the patient had fallen asleep after ha^dng passed the catheter in the early hours of the morning and retired again. Subsequent search failed to discover the whereabouts of the instrument until symptoms of the presence of a calculus exj^lained the mj^stery. In speaking of forced catheterization and the production of false passages, it was not intended to convey the impression that in competent hands it is possible to reach the bladder in aU cases, and without acci- dent. It is true that if the skillful surgeon were to persist he would do as much harm as the novice. The former, however, will generally per- ceive when an unjustifiable degree of force is being employed, and desist, ha-^-ing at his command other means for accomplishing the desired object. The ignorant and careless practitioner, however, believing that he must enter the bladder with the catheter whether or no, proceeds to plow his way through with a metal instrument, resrardless of consequences. Other Methods of Emptying the Bladder.— T\nien the difficulties in the way of emptying the Ijladder, in a case of retention of urine, are such as demand of the prudent surgeon the substitution of other means than SURGICAL MALPRACTICE. 027 those having for their object the reaching of the urinary viscus by the natural channel, the question of the choice of other methods of empty- ing the bladder will arise. Without doubt the first choice at this period will be tlie method of aspiration. It should l)e borne in mind in this connection that relief of the over-distended viscus ]>y aspiration will fi-eqnently i)ermit of the subscijiieiit emptying of the latter l)y means of a catlieter through the natural channel. The operation may be done above the pubes Avithout injury to the peritoneum, and may be repeated two or three times in twenty-four hours, thus giving the patient relief until catheterization is possible or other measures are devised for his permanent rehef. The preference for as})iration over supra})ul)ie })uncture by a large ti'oear and cannula is V)ase(l upon the fact that, with the latter, urinary infiltration of the abdominal walls nvAj occur aiul lead to serious phleg- monous inflammation of these structures. Incision above the pubes may be done if the external wound be made sufficiently large to permit of ready escape of the urine ; but this is an operation rarely performed for retention. Permanent Catheterization. — The permanent retention of a catheter when once the bladder has been reached through the natural route also has its dangers. A metal instrument will rarely be tolerated for more than a few hours, and a soft rubber catheter cannot, as a rule, be em- ployed in difficult catheterization. Whatever instrument is used, the concentrated character of the urine in these cases produces rapid in- crustation from the deposit of the salts, and these, becoming displaced, form nuclei for vesical calculi. Circumcision. — Both hemorrhage and sepsis follow this operation. In the ritual operation the mohl or rabbi not infrequently removes a slice of the glans also. In later life the sear resulting from this actcident may be mistaken foi* that whicli has followed a chancre, the i)atient being w^'ongfully accused l)ecause of its presence. In the ritual operation the internal or mucous-meml.)rane surface of the prepuce is torn instead of being incised, and the rent thus made may extend, beyond the corona glandis upon the dorsum of the penis. In France the presence of a sur- geon is required by law at all ritual circumcisions. Failure to keep the prepuce well retracted after the operation nuxy lead to the formation of a cicatricial ring of the mucocutaneous tissues about the glans lieyoiul the corona glandis and necessitate a second operation. This mishap may also result from the removal of an insuffi- cient portion of the prepuce. Inexperienced operators sometimes become alarmed at the swelling along the suture-line, and make the attempt to remove still more of the prepuce after two or three days. The result of these attempts is usually such as to leave the parts in a much worse condition than l)efore. . Hydrocele. — In the operation of tapping a hydrocele the nu)st com- mon accident consists of an injury to the t(*sticle. Hematocele, orchitis, or even abscess, may result. Another accident is the slii)})ing of the cannula from the sac of the tunica vaginalis, thus allowing tlie contents of the latter to How into the cellular tissue, where it may cause a phleg- mon or even terndnate in gangrene of the entire scrotum. The first-named accidents arise from a failure on the pai't of the oper- .ator to bear in mind that the testicle lies behind and upward, where, 628 ^ SYSTJEM OF LEGAL MEDLCIXE. under ordinary cii'cnmstances, -with proper care it may almost al^rays be avoided. It has happened more than once that the practitioner who is little accustomed to operating and to the care of instruments cleanses the trocar after an operation and puts it away, o^-ei'looking the cannula. When next it is needed the trocar alone is plunged into the hydrocele. Again, it may happen that he neglects to ascertain if the trocar can be withdrawn from the cannula. After the puncture he essays to do so, but finds it so thoroughly fastened by corrosion or rust to the cannula that they cannot be separated. Abscess of the Testicle. — Prolapse of the seminiferous tubules is an accident occurring in the course of an abscess of the testicle. An ugly,. grayish-looking mass is seen projecting from the abscess cavity, which the inexperienced practitioner may mistake for an ordinary slough, and attempt to remove it ■with the dressing-forceps ; remo^ang thus meter after meter of the tubules until several or even all of the lobuli testes are evacuated, the etfeet being the same as castration. Cauterization of the prolapsed mass and crowding it by means of the dressings as much as possible into the lobule from which it projects, is the proper treatment. Castration. — Separate ligature of the vessels of the cord, although apparently a typical procedure, is less to be relied upon than ligature en masse. Even with the latter method, unless the operator is careful tO' divide the structures of the cord for at least three foiu'ths of an inch away from the point of ligature, the action of the cremaster may so re- tract the vessels as to cause troublesome hemorrhage. The vas deferens . need not be included in the ligatui'e. In malignant disease of the tes- ticle and cord this extends along the seminal duct proper, and recm-reuce takes place sooner or later, as a rule. A^mlsion of the vas deferens- should be done in order to guard as much as possible against this result, the vas being twisted and withdi'awn at the same time. In this manner the entire vas deferens, from the point where it joins the ejaculatory duet of the corresponding vesicula seminalis at the base of the prostate to the internal abdominal ring, may be removed. Operations for Vesical Calculus. — All of the operations for the re- lief of stone in the bladder are liable to some mishap or accident. While the operation of suprapubic lithotomy possesses some advantages, par- ticularly in the removal of large stones which cannot be crushed, yet there is always great risk of urinary infiltration if the wound is closed at once. If it is left open there is less risk of infiltration, although im- munity from this cannot be assm-ed in any case ; yet the length of time required for healing is such as to severely tax the reparative powers of the aged and feeble, in whom, unfortunateh', this operation is called for more frequently than in the young and vigorous. In addition to this the dangers attending the use of the rectal balloon of Petersen, which is- used to facilitate the elevation of the bladder, are to be noted. In my own experience the use of the Petersen rubber balloon resulted in a rupt- ure of the anterior wall of the rectum, although but eight ounces of fluid were used to distend it. {Annals of Sim/fri/, vol. xii., 1890, p. 129.) Two other cases are reported (Cadge, P)-oc. Boijal Med. and Cliir. iSoc, London, 1886, p. 97; Nicaise, quoted hy Keyes in Annual of Universal Medical Sciences., 1888, Section C, p. 27.) Median perineal lithotomy, on the other hand, admits of the removal of moderate-sized calculi only, and SUnaiL'AL MALI'llACTICE. 629 hence its application in the treatment of calculous disease is limited. The combination of perineal section and lithotrity (perineal lithotrity : Nussbaum of Muiii(,'h, Doll)eau of Paris) offers some advantaj^es, but is limited in its application. Lateral lithotomy, while it admits of the re- moval of a rather larg-er stone than the median operation, has been ac- cused of causing- sterility because of injmy to the seminal vesicles or to the ejaculatory ducts. Again, the rectum is more apt to be injiu-ed in lateral lithotomy, particularly if tenesmus and prolapse of the bowel have been prominent features in the histor}- of the case. Urethro-rectal fistula results. In lithotomy in a number of sittings, as practiced previous to the introduction of Bigelow's metliod of lithotomy at a single sitting and complete evacuation of the fragments throng] i a large uretkral tube (litholapaxy), it sometimes happened that pointed fragments remained in the bladder to torment the patient in the intervals between the seances. In addition to this the surgeon coidd never be sure that all of the small fragments had been passed, and patients have frequenth^ returned with from four to eiglit stones, small fragments which had been left having served as nuclei of new stones. Although these mishaps are prevented to a great extent by the method of litholapaxy, together with the use of Bigelow's large evacuatiiig-tubes and force-pump apparatus for removing all fragments from the bladder, yet there is one accident which may occur in inexperienced hands in both lithotrity and litholapaxy. This is the catching of a fold of the mucous membrane lining the bladder between the blades of the crashing instru- ment, and consequent injury to this structure. In order to avoid this the sui'geon should never forget, after having seized the calculus, to rotate the instrument in order to ascertain whether or not it mo\'es freely in the bladder. A stone may be previously detected and its presence verified by the surgeon's colleagues, and jet not be discoverable at the time of the oper- ation. This is due to the fact that the stone is small and falls into a recess of the bladder, the w^alls of the latter closing over it. In order to avoid this awkward predicament it is advisable for the surgeon to make sure that the stone is within reach just prior to the administration of the anaesthetic at the time of operation. Extravasation of Urine. — This accident may follow the giving way of the urethra at a point behind an old stricture, from long-continued pressure and the changes which the mucous membrane undergoes in con- sequence ; or it may result from injuries to the canal, occurring from the injudicious use of metal instruments in attempts at forced catheteri- zation, and also from lacerated and contused wounds of the perineum from without. Crush injuries of the pelvis, with fracture of the bones of the latter, may also be complicated with rupture of tlie urethra and urinary extravasation. Fracture of the corpora cavernosa during erec- tion, either from a sudden bending of the peids by the grasp of the hand or ^'iolent coitus, likewise gives rise to this condition. Faihire to I'ecognize the occurrence of extravasation is a grave error, and is likely to result in most serious consequences. In case the solu- tion of continuity is behind the bull) this will lead to infiltration of the scrotum, fi'om Avhich hx'ality the extravasation will be directed betAveen the spine of the pubes and the symphysis, finally reaching the abdo- G30 ^ SYSTEM OF LEGAL MEDICINE. men. In tlie penile nretlu-a the ruptni'e will be followed by a swelling of the penis, which reaches its maximiun in the neighborhood of the point of escape. At the membranous urethra the extravasated urine is confined between the layers of the triangular ligament, from which it subsequently escajDCS by processes of sloughing and suppuration. At the prostatic urethra, i.e., behind the posterior layer of the triangular liga- ment, the extravasation may find its way to the anal region in the peri- neum by following the coiu'se of the rectum ; or the thin pelvic fascia may give way at its thinnest point near the pul^oprostatic ligament, thus permitting the extravasation to spread through the subperitoneal con- nective tissue. In whatever direction the urine finds its way, its presence in the tis- sues gives rise, unless speedy measui'es of relief by free multiple incisions and thorough disinfection of the infected parts are instituted, to rapid sloughing of the connective tissue, gangi*ene, general sepsis, and death. APPEISTDIX.* EXTEACTS FKOM THE LAWS OP THE DIFFEEENT STATES AND TEEEI- TOEIES OF THE UNITED STATES WHICH EELATE TO THE GENEEAL CAEE OF THE INSANE. The following pages relate more particularly to the duties and responsibilities of physicians and officers of the law in reference to committing insane persons to insti- tutions for care and treatment, tlieir general management while under treatment, and their discharge from institutions. As the laws of the States differ very considerably in reference to the form of pro- ceeding necessary to be followed in these several respects, it is thought desirable that from the great body of statutes relating to the management of the insane such extracts as relate to the duties of phj'sicians slioidd be compiled and made easy for reference. It is believed that the following arrangement will prove to be of service, especially to general practitioners. Acts op Alabama, 1886-87. Regulating the Admission and Discharge of Patients in the Alabama Insane Hospital. Section 1. — Be it enacted by the General Assembly of Alabama that the word " in- sane," where it occurs in the act incorporating the Alabama Insane Hospital, shall be construed to mean any person who, by reason of an unsound mind, resulting from dis- ease of brain, is incapable of managing and caring for his own estate without danger to himself or others if permitted to go at large, or is in such condition of mind or body as to be a tit subject for care and treatment in the hospital for the insane ; j)ro- vided, that no person idiot or imbecile from birth, or whose mental development was arrested by disease or physical injury prior to the age of puberty, or any person who is afflicted with simple epilepsy, shall be regarded as insane, unless the manifestation of abnomnal disability, ■\dolenee, homicidal or suicidal impulses are such as to render his eoufiinement in the hospital a proper protection to prevent him from injiudng him- self or others. Sec. 2. — Be it further enacted that authority to discharge patients from the hos- pital is vested in the trustees, and may be delegated by them to the superintendent under such regulations as they may see proper to adopt. . . . Sec. 3. — Be it furtlier enacted that the superintendent of the hospital has author- ity to fui'lough, for a period not exceeding six months, such of the harmless and con- valescent patients as in his opinion may be benefited by the change. . . . Proviso to effect that expenses of furlough V)e borne by the parties. Sec. 4. — Be it further enacted tliat persons confined as insane shall be entitled to the benefit of a writ of habeas corpus. . . . * This concise epitome of the laws relative to the insane has been made and pub- lished by Dr. H. P. Stearns, and is used with Ms kind permission. 631 632 APPENDIX. Eevised Code of Alabama, 1886-87. Sec. 1237. — Order of Admission. In order of admission the indigent insane must have precedence of the rich, and recent cases of both classes must have precedence over those of long standing. The paying patients from other States may be received into the hospital should vacancies occin- unclaimed by natives or residents of Alabama. Sec. 1241. — Investigation of Insanity and Admission to Hosintal of Indigent Persons. "When a person in indigent circumstances becomes insane, application can be made by his friends or any other person, in his behalf, to the judge of the Probate Court in the county where he resides, and such judge must without delay make appli- cation to the superintendent of the hospital for his admission. . . . "\ATien informed that the applicant can be received the judge must call one respectable physician and other triistworthy witnesses and fully investigate the facts in the ease, and either with or without the verdict of a jury, at his discretion, must decide the case as to insanity and indigence ; and if the judge believe that satisfactory evidence has been adduced showing the patient to be insane, and his estate insufficient to siipport him and his family (or himself alone, if he has no family) imder the visitation of insanity, he must, upon the judge's certificate, be consigned within thirty days to the hospital, at the expense of the county, and be supported there at the expense of the State ; and the superintendent shall be required to keeji the vacancy for a period of thirty days after the date of notice that patient can be received. The judge in all such cases shall have the requisite power to compel the attendance of witnesses and jiu'ors, and must file the certificate of the physician and other papers relating to the case, with a report of the proceedings and decision. Sec. 1249. — . . . No patient must be received or discharged without suitable clothing, and if it cannot otherwise be obtained the steward must furnish it and charge the same to the county from which he was sent. The patient must also be furnished by the steward, if it is not otherwise to be had, with money sufficient, not to exceed twenty dollars, to pay his expenses until he reaches home ; and the cost of clothing and money advanced must have precedence over other claims, and be repaid promptly, by the commissioners of the county from which the patient comes, into the county treasury. Revised Statutes of Arizona, 1887. Insane Persons. Paragraph 2156, Section 1. — 'The probate judge of any county in this Territory, upon the application under oath setting forth that a person by reason of insanity is dangerous, being at large, shall cause such a person to be brought before him for examination, and shall cause to be summoned to appear at such examination two or more witnesses acquainted with the accused at the time of alleged insanity, who shall be examined on oath as to the conversation, manners, and general conduct of the accused upon which «uch charge of insanity is based; and shall also cause to appear before him one or more graduates of medicine, and known to be reputable jDracti- tioners thereof, who shall be present at such examination and personally examine accused, and shall set forth in written statement to be made by one of them, first, his or their judgment as to the insanity of the person charged ; second, whether it be dangerous to the accused, to the person or property; third, whether such insanity is in his or their opinion likely to prove permanent or only temporary ; and upon such a hearing and statement as to the aforesaid, if the proofs shall satisfy the judge before whom such hearing is had that such party is insane, and that by reason of his or her insanity he or she be in danger, if at liberty, of injuring himself or herself, or the person or property of others, he shall, by an order entered by record in a liook kept for that purpose, direct the confinement of such person in the Territorial Insane Asylum, who shall be confined therein and not discharged until sufficiently restored to reason. Par. 2157, Sec. 2. — The principal supervisors of each county shall cause such. APPENDIX. g:33 person to be conveyed to tlie Territorial Insane Asylum, and shall present for tlie safe confinement and care of such person suitable i)lace in such asylum, and shall draw their warrants in payment of proper costs and cliarges tlierefor upoji the county treasury ; and the county treasury shall pay such warrants out of tlie general fund, as other warrants are paid from such fund; ]>rori(lc(l, that such insane person shall have no money or property from which said cost and charges may be paid, according to the provision of this act. Acts op Arkansas, 1889. Sec. 1. — Female AUendunt to he Provided. That all females wlio have been adjudged insane by proper authorities shall be accompanied from the county-seat, so adjudged, to the insane asylum by at least one female as an attendant or protector, and the said female attendant shall receive the same compensation as is now paid to male attendants for the same service. Act II. Sec. 1. — Privileges of Inmates in Correspondence. That from and after the passage of this act each and every inmate of each and every insane asylum, either public or private, in the State of Arkansas, shall be allowed to choose one individual from the outside world to whom he or she may write when and whatever he or she desires, and over these letters to this individual there .shall be no censorship exercised or allowed by any of the asylum officials or em- ployees, but their post-office rights, so far as this one individual is concerned, shall be as free and unrestrained as are tliose of any other resident or citizen of the United States, and shall be under the protection of the same postal laws ; and each and every inmate shall have the right to make a choice of the individual party every three months, if he or she so desire to do. And it is here made the duty of the superintendent to furnish each and every inmate of every insane asylum, either public or private, in the State of Arkansas, with suitable material for writing, inclosing, sealing, stamping, and mailing letters, sufficient at least for writing of one letter per week, provided they request the same, unless they are otherwise furnished with such material, and all such letters shall be dropped by the writers thereof, accompanied by an attendant when necessary, into a post-office provided by Congress at the insane asylum and kept in some place of easy access to all patients ; the attendant is required in all cases to see that this letter is directed to the patient's correspondent, and if it is not so directed it must be held subject to the superintendent's disposal ; and the contents of these boxes must be collected once every week by an authorized person from the Post-office De- partment, and by him placed' in the hands of the United States mail for delivery. Sec. 2. — Duties of Superintoident. That it is hereby made the duty of the superintendent to keep registered and posted, in some pviblic place at the insane asylum, a true copy of the names of every individual chosen, and by whom chosen, and it is hereby made the duty of the super- intendent to inform each individual of the name of the party choosing him or her, and he is to request him or her to write his or her own name on the outside of the envelope of every letter he or she writes to tliis individual ; and all these letters bearing the individual writer's name on the outside he is required to deliver, without opening or reading the same, or allowing it to be opened or read, unless there is reason for believ- ing the letter contains some foreign substance which might be used for medication, in which case the letter shall be required to be opened in the presence of a competent witness, and this substance shall be delivered as directed. Sec. 3. — Violation of the Act hij Persons Connected with Jsj/lnms a Misdemeanor. That violating upon conviction thereof sluiJl he pui ■describes for misdemeanor, and by ineligibility to any office in the asylum afterward. 634 APPENDIX. Sec. 4. — Copy of this Act to he Posted in Wards of the Asylum. That a printed copy of this act shall be kept posted in every ward in every asylum,, both public and private, in the State of Arkansas. Digest op the Statutes of Arkansas, 1884. Sec. 3811. — Lunatic Previously Mad may be Confined. If any person who has been previously mad, or so far disordered in his mind as to- endanger his own person or the person or property of others, shall again become in- sane, it shall be the duty of his guardian or person under whose care he may be, and who is bound to provide for his support, to confine him in some suitable place imtil the next term of the Probate Court for his county, which shall make such order for the restraint, support, and safe-keej)ing of such person as the circumstances of the case shall require. Sec. 3812. — Judge or Justice may Order Confinement. If any such person of unsound mind as in the last section specified shall not be confined by those ha'V'ing charge of him, or if there be no person having such charge, any judge of a court of record, or any two justices, may employ any person to confine him in some suitable place until the coui't shall make further order thereon, as in the preceding section specified. Sec. 3814. — Insane Persons Found at Large. Insane persons found at large and not in the care of some discreet person shall be arrested by any peace officer and taken before a magistrate of the county, city, or town in which the arrest is made. Codes and Statutes of California, 1886. Examination and Committal of Insane Persons. Sec. 2210. — Examined before Whom. Whenever it appears by affidavit to the satisfaction of the magistrate of the county that any person within the county is so far disordered in his mind as to endanger health, person, or property, he must issue and deliver to some officer, for ser^sdce, a warrant directing that such person be arrested and taken before any judge of court of record within the county for examination. Sec. 2211.— Tico Witnesses. When the person is taken before the judge he must issue subpoenas to two or- more witnesses best acquainted with such insane person, to appear and testify before him at such examination. Sec. 2212.— Tm;o Physicians. The judge will also issue subpoenas for at least two gradu'lates of medicine to appear and attend such examination. Sec. 2214. — Diity of Physician. The physician must hear such testimony, and must make a personal examination of the alleged insane person. Sec. 2215. — Certificate of Physicians. The physicians, after hearing the testimony and making examination, must, if they believe such person to be dangerously insane, make a certificate showing as near as possible : First, That such person is so far disordered in his mind as to endanger health,, person, or property. APPENDIX. G35 Second, The premonitory symptoms, apparent cause, the class of insanity, the duration and condition of disease. Third, The nativity, age, residence, occupation, and previous lial)its of the person. Fourth, The i>hice from whence the person came, and the lengtli of his residence in this State. Sec. 2i!17. — Dutij of the Judge inid Clerk on Commitment of Innanc. The judge, after such examination and certificate made, if he believes the person so far disordered in his mind as to endanger health, person, or projierty, must make an order that he be confined in tlie insane asylum. A copy of such order shall be filed witli a record by the clerk of the coimty. The clerk shall also keep in convenient form an index-book showing name, age, and sex of person so ordered to be confined in the insane asylum, with the date of the order and the name of the insane asylum in which the person is ordered to be confined. No fees shall be charged by the clerk for performing any duties provided for by this section. Sec. 2222. — Fees of PJnjsicians. The physicians attending such examination of an insane person are allowed five dollars, which are to be paid by the treasui'er of the county where the examination was had, on the order of the supervisors. Code of Colorado, 1883. 2281 — Sec. 28. — (2) Arrest of Various Lunatics — I)iquest — Verdict — Commitment — Custodjj. "Whenever any reputable person shall file with the county court a complaint, duly- verified, alleging that any person is so insane or distracted in mind as to endanger his own person or ju'operty, or the person or pi*operty of any other or others, if allowed to go at large, the coimty coui't, or judge thereof, shall forthwith issue an order in the name of the people direct to any sheriff or constable of the county, for the apprehen- sion of such alleged insane person, which order may be executed by any sheriff or eon- stable of said coimty, or by any person especially appointed by said coiu't to execute the same ; prorided, that when any sheriff or constable shall find within his county any such insane person at large, it shall be his duty to apprehend such insane person without an order of the court. And when any alleged insane person shall be an-ested by or without an order of the court, he or she shall be taken forthwith before the county court, or judge thereof, and if the alleged insane person so elect, an inquest, as provided for in section 1, shall be held without delay; and until the determination of such inquest such alleged insane person shall be confined in the county jail or other convenient place. If upon such inquest it shall be found in the verdict of the jury that such alleged insane person is so insane or distracted in mind as to endanger his or her own personal property, or the person or property of any other or others, if allowed to go at large, it shall be the duty of the court to commit such insane person to the county jail or other convenient place, to be there confined until discharged on inquest or otherwise disposed of according to law. . . . 2237— Sec. 34:.— Definition of the Term "Lunatic" The term "lunatic," as used in this chapter, shall be construed to include idiots, insane and distracted persons, and every person who, by reason of intemperance or any disorder, or unsouncbiess of mind, shall be incapable of managing and caring for his own estate. Sec. 2241. — Superintendent and Commissioners to Report AnnuaJJii. The superintendent of the Board of Commissioners shall make a report to the governor on or before the first day of December in each and every year, showing the condition of the asylum financially, number, age, sex, occupation, and residence, treatment and state of reform of persons admitted, from the date of opening of the asylum or from tlie date of the last report, together with siicli otlier facts as their experience and observation may approve and may deem in the interest of tlie public ; the governor shall cause such reports to be published, and he shall present them to the next general assembly. . . . 636 AFFENDIX. Acts of Connecticut, 1889. Chapter 162, Section 1. — In this act the words and expressions following shall have the several meanings hereby assigned to them, unless there is something in the subject or context repugnant to such construction. That is to say, "asylum" means any public or private hospital, retreat, institution, house, or place in which any insane person is received or detained as a patient for compensation, but shall not include any ytate-prison, county jail, or poorhouse, nor any public reformatory or penal in- stitution of this State. " Insane person " means and shall include everj^ idiot, non compos, lunatic, insane, and distracted person. " Patient " means any person detained and taken care of as an insane person. The words "keeper of an asjdum" mean any person, body of persons, or corporation who have the immediate superintendence, charge, management, and control of an asylum and the patients therein. Words im- porting the masculine gender may be applied to females. Sec. 2.^ — Any judge of a Proijate Court, within his probate district, shall have power to commit any insane person residing in said district to an asylum in this State, in the manner hereinafter provided. Sec. 3. — Except when otherwise specially provided by law, no person shall be committed or admitted to an asylum without an order signed by a judge of probate, as hereinafter provided. Sec. 4. — Whenever any person in this State shall be insane, or s-hall be supposed to be insane, any person may make complaint in writing to any judge of probate within whose district the person complained of shall reside, alleging that such person is insane and is a fit subject to be confined in an asylum ; and when any insane person who ought to be confined shall go at large in any town, any person may, and the selectmen thereof shall, make a like complaint to the judge of probate within whose district such town is included. After receiving said complaint, the judge to whom it is made shall forthwith appoint a time, not later than ten days after receipt of said complaint, and a place within said district, for a hearing upon said complaint, and shall cause reasonable notice thereof to be given to said complainant, to the person complained of, and to such relative or relatives of said person, or to any person in- terested in said person, as said judge shall deem proper, and maj^ adjourn said heai'- ing from time to time for cause. Said judge may issue a warrant for the apprehehsion and bringing before him of said person complained of, and shall see and examine said person, if in his jiidgment the condition or conduct of such person renders it necessary and proper so to do, or state in his final order whj^ it was not deemed necessary or advisable so to do. Sec. 5. — In addition to such oral testimony as may be given before such judge, at said hearing, there shall be filed with such judge a certificate signed by two physi- cians, each of whom is a graduate of some legally organized medical institution and has practiced three years in this State, and neither of whom is connected with any asylum nor related to the person complained of by blood or marriage. Each must have personally examined said person alleged to be insane, within five days of signing said certificate, and each shall certify that, in his opinion, said person is insane and a proper subject for treatment in an asj'lum ; and a copy of said certificate, attested by said judge, shall be attached to the final order of said judge and delivered with said order to the keeper of the asylum to which said insane person shall be committed. Sec. 6. — If, on said hearing, the judge shall find that the said person is insane, and a fit subject for treatment in an asylum, or that he ought to be confined, he shall make an order in writing, stating that lie so finds, and commanding some proper officer, or auy fit person, to convey said insane person to the asylum named in said order, unless some person shall undertake, before said judge, and shall give bond to the State conditioned to confine such person in some suitable place of detention, not an asylum, in such manner as said judge shall order. . . . Sec. 16. — All insane persons confined in any asylum in this State shall be entitled to the benefits of the ^^ait of habeas corpus, and the question of insanity shall be determined by the court or judge issuing such writ, and if the court or judge before whom such case is brought shall decide that the person is insane, such decision shall be no bar to the issuing of said writ a second time, if it shall be claimed that said person has been restored to reason. Said writ may be applied for by said iiisane per- son, or on his belialf by any relative or friend, or person interested in his welfare. Sec. 17. — Tlie provisions of this act shall not extend to nor affect in any way the cases of persons convicted of or charged with crime, as provided for in the following Ari'ENDix. c;J7 sections of the General Statutes— to wit, sections IGOO, IGOl, 1G02, 1003, 3385, 338G, 3615, 3617, 3618, 3619, 3620, and 3621 ; nor sliall tliey be construed as reijealing sec- tions 487, 3683, and 3684 of said (jieneral Statutes. Skc. 18. — The keeper of any asylum in tliis State may receive and detain therein, as a patient, any person wlio is desirous of subinittinfj liiniself to treatment and makes written application therefor, but wliose nieiital condition is ncjt such as to ren- der it legal to grant an order of comniitnient as an insane jK-rson in his case, under tlie provisions of this act. No such patient slmll be dctaiued for more tliau three days after having given notice in writing of liis intention or desii-e to leave said asylum. Skc. 19. — An attorney at law regidarly retained by, or on Ijelialf of, any patient in an asylum, or any medical practitioner designated by sucli patient, or by any member •of his family, or by some relative or friend of such patient, sliall V)e admitted to visit such patient at all reasonable hours, if in the opinion of tlie keeper of said asylum such visit woidd not be injurious to said patient, or if a judge of the Sui^erior Court first orders in writing that such visit be allowed. Sec. 20. — All persons detained as insane shall at all times be furnished with materials for connnunicating with any suitable person without the asj'lum, and such communications shall be stamped and mailed daily. Should the patient desire it, all rational communications shall be written at his dictation and duly mailed to any rela- tive or person named by the patient. Sec. 22. — All asylums in this State sliall be subject to tlie inspection and visita- tion of tlie State Board of Charities, and shall be so visited and inspected at least once in six months in each year. Sec. 23. — Every person Avho willfully conspii*es with any other person unlawfully to commit to an asylum any person who is not insane, and any person who shall will- fully and falsely certify to the insanity of any person in any certificate made and filed as provided for in this act, and any person who shall willfully and falsely report to any court or judge that any person is insane, shall be ])unished by a fine not exceed- ing one thousand dollars, or by imprisonment in the State-prison not exceeding five years, or both. Sec. 24. — Every keeper of an asylum who shall willfully violate any of the J)ro^^s- ions of sections 3, 18, 19, and 20 of this act shall be deemed guilty of a misdemeanor, and may be punished by a fine not exceeding two hundred dollars, or by imprisonment in a common jail not exceeding one year, or both, at the discretion of the court. Sec. 25. — All acts or parts of acts inconsistent herewith are hereby repealed. Laws of Dakota Territory, 1887. Sec. 2179. — Appointment of Co'mmissio)iers of Insanity . In each organized county of this Territory there shall be a board of commissioners, ■consisting of three persons, to be styled Commissioners of Insanity, two of whom shall constitute a quorum. ... Sec. 2182. — Duties of the Commissioners and tlieir Power. The said commissioners shall have cognizance of all applications for admission to the hospital, or for the safe-keeping otherwise of insane pei'sous within their respect- ive counties, except in eases otherwise specially provided for. For the purpose of discharging the duties required of tliem thej' shall have the power to issue subpoenas and compel obedience thereto, to demonstrate tliis and any act of the court necessary and proper in the premises. Sec. 2183. — Applieati<»i for Admission to the Ilospital. Application for admission to tlie hospital must be made in WTiting, in the nature ■of an information, verified by affidavit. Sucli information must allege that the person on whose behalf ajiplication is made is believed by the informant to be insane, and a fit subject for custody and treatment in the liospital ; if siicli person is found in the coimty and has a legal s(>ttlement thert>in, if such is known to be the fact ; and if such settlement is not in tlie county, where it is, if known, or where it is believed to be, if the informant is advised on the subject. 638 APPENDIX. Sec. 2184. — Investigation bi/ Commissioners as to the Alleged Insanity — Physician's Certificate. On the filing of the information as above provided the commissioners shall at once take steps to investigate the grounds of the information. For this purpose they may require that the person for whom such admission is sought be brought before them, and that the examination be had in his or her presence, and they may issue their war- rant therefor and provide for the suitable custody of such person until their investiga- tion shall be concluded. . . . Any citizen of the county, or any friend of the person alleged to be insane, may appear and resist the application, and the parties may ap- pear by counsel if they elect. The commissioners, whether they decide to dispense with the presence before them of such person or not, shall appoint some regular prac- ticing physician of the county to visit or see such person and make personal exam- ination touching the truth of the allegations in the information touching the actual condition of such person, and forthwith rejjort to them thereon. Such physician may or may not be of their own number, and the physician so acting shall certify, under his hand, that he has, in pursuance of his appointment, made careful personal exam- ination as required, and after such examination he found the person in question in- sane, if such be the fact, and, if otherwise, not insane ; and in connection with this examination the said physician shall endeavor to obtain from the relatives of the per- son in question, or through other friends who know the facts, correct answers, as far as may be, to the interrogatories hereinafter required to be propoiinded in such cases, and such interrogations and answers shall be attached to this certificate. Sec. 2185. — Mow Patients should he Sent to the Hospital. On the return of the physician's certificate the commissioners shall, as soon a& practicable, conclude their investigations, and having done so they shall find whether the person alleged to be insane is insane; whether, if insane, a fit subject for treat- ment and custody in the hospital ; whether the alleged settlement of such person is in their county ; if not in their county, where it is, if ascertained. If they iind such per- son is not insane they shall order his or her discharge, if in custody. If they find such person insane and a fit subject for treatment and custody in the hospital, they shall forthwith issue their warrant and a dui^licate thereof, stating such a finding, with the settlement of the person, if found, and, if not found, their information, if any, in regard thereto, authorizing the superintendent of the hospital to receive and keep such person therein. Such warrant and duplicate, with the finding and certifi- cate of the physician, shall be delivered to the sheriff of the county, who shall execute the same hj conveying such person to the hospital and delivering him or her, with the- duplicate of the physician's certificate and finding, to the superintendent thereof. The superintendent, over his official signature, shall acknowledge such delivery on the- original warrant, which the sheriff shall return to the clerk of the commissioners, witk his cost and expenses indorsed thereon. . . . Sec. 2190. — Penalty for Cruelty to the Insane. Any person having care of any insane person and restraining such person, either with or without authority, who shall treat such person with wanton severity or harsh- ness, or shall in any way abuse such person, shall be guilty of a misdemeanor, besides being liable to an action for damages. Sec. 2199. — Postal Privileges of Inmates. Henceforth each and every inmate of each and every insane asylum, both public and private, in the Territory of Dakota, shall be allowed to choose one individual from the outside world to whom he may write when or whatever he desires, and over these letters to this individual there shall be no censorship exercised or allowed by any asylum official or employee, but their post-office rights, so far as this one indi- vidual is concerned, shall be as free and unrestricted as are those of any other resi- dent and citizen of the Territory of Dakota, and shall be under the protection of the same postal laws ; and each and every inmate shall have the right to make a new choice of this individual party every three months if he so desires to do. And it is hereby made the duty of tlie superintendent to fiu-nish each and every inmate of the insane asylum in this Territory, either public or private, with suitable material for A I' VEND IX. 63{> writing, inclosing, sealing, stamping, and mailing letters, snfficient at least for the ■writing of one letter a week, iirovidiiig they request the same, unless they are other- wise furnished with such material, and all such letters shall be dropped by the writers thereof, accompanied by the attendant when necessary, into a post-olHce box provided at the insane asylum and kc})! in some place easy of access to all patients ; the attend- ant is required in all cases to see that this letter is directed to the patient's corre- spondent, and if it is not so directed it must be held subject to the disposal of the superintendent ; and the contents of this box shall be collected once every week Ity an authorized person of the Post-office Department, and by him placed in the hands of the United States mail for delivery. Laws op Delaware, 1887. Title 60, Chapter 92, Section 1. — Proceedings in the Case of Indigent Lunatics. Be it enacted (etc.) that whenever the relatives or friends of an indigent lunatic or insane person, a citizen of this State, shall apply to the chancellor of this State, either personally or by petition, together with the certificate of two practicing physi- cians of the county wherein such lunatic or insane person shall reside, one of whom shall be the regular physician of the almshouse of said county, setting forth the facts of said lunacy or insanity, the cause or causes, if known, and the necessity, in their opinion, of a better and more efficient mode of medical treatment in such case than can be afforded in the almshouse Avherein such lunatic or insane person may reside, the chancellor shall, if satisfied with the proofs offered of such lunacy or insanity, refer such applications to the trustees of the poor of said county for information as to indigency of said person for whom application is made, or any other matter ; where- upon, if said reports be satisfactory, the chancellor shall recommend to the governor that such indigent lunatic or insane person be removed to the Insane Department of the New Castle County Almshouse ; proinded, that not more than ten indigent lunatic or insane persons from each of the counties of Kent and Sussex shall be in said asylum at the same time ; and provided further, that this shall not prevent the trustees of the poor of either county of Sussex or Kent from placing any indigent lunatic or insane person that may be placed in their keeping in the said Insane Department of the New Castle County Almshouse for whom no application may be made, and who, in their opinion, may require special treatment. Sec. 3. — When Indigent Lunatics may he Bcturncd. That whenever the principal physician of the Insane Department of the New Castle County Almshouse shall represent to the trustees of the poor of the county from which said indigent lunatic or insane person may have been entered that any such person has been cured by the treatment prescribed, or they are so far benefited and improved in condition as to render his or her further residence in said Insane Depart- ment iranecessary, or that the said person is, after full and sufficient opportimity, incurable, then he or she shall, upon the written request of said Insane Department, if cured or relieved as aforesaid, be discharged from said institution ; or if incurable as aforesaid, be returned to the almshouse for cure and confinement. Laws of Delaware, 1889. Chapter 553, Section 9. — In all cases of application for the commitment of an insane person to the hospital the evidence and certificate of at least two respectable physicians, based upon due inquiry and personal examination of the person to whom insanity is imputed, shall be required to establish the fact of insanity, and a certified copy of the physician's certificate shall accompany the person to be committed, to- gether with the written order of the trustees or chancellor, as provided in section 6 of this act. Digest, Laavs of Florida, 1881. Chapter 147. — Lunatics. Sec. 3. — Duty of the Circuit Judge. "Whenever it shall be suggested, by petition or otherwise, to any jiidge of the Cir- cuit Court of this State that there is any lunatic or insane person within the limits of the judicial circuit of said judge incapable of managing his or her o\\^ affairs, or of ■640 ArrE2\Dix. taking care of himself or herself, it shall be the duty of said judge to issue a writ to the sheriff of the county wherein such lunatic or insane person is alleged to be, direct- ing him to bring such person before him for the purpose of inquiring into the alleged lunacy or insanity. Sec. 4. — If it is found upon investigation that such person is a lunatic or insane, the judge shall pass such order or decree as is usually necessary in such cases. Sec. 6. — Order for Lunatic to he Taken to the Asylum — Order for Private Care of Lunatic. If it shall appear that said lunatic or insane person is destitute, then the judge shall draw an order that the sheriff shall transport such lunatic or insane person to the Asylum for the Indigent Limatics of the State of Florida, and there deliver the lunatic or insane person to the officer having charge of same, for the pin-pose of his care, custody, and treatment ; provided, however, that the judge may, in his discretion, direct the said lunatic or insane person to be delivered to any other person for his care, custody, and maintenance, in which event the said insane person shall be so delivered, and it shall be the duty of the person to whom such delivery is made to provide for his care, custody, and maintenance. . . . Sec. 12. — Care of Lunatics for Pay. It shall be lawful for the physician in charge of the Asylum for Indigent Lunatics of the State of Florida, when directed by the Board of Commissioners of State Institu- tions, to receive into said asylum any lunatic, idiot, or insane person whose fi'iends, parents, or guardians are able and willing to pay for the care and custody and main- tenance of said lunatic, idiot, or insane person. Sec. 13. — Attention, etc. Such lunatic, idiot, or insane person shall receive all care, food, clothing,, and medical attention as he or she may demand and require, from the physician and other employees of the asylum. Sec. 17. — Powers. The physician of the asj^lum shall have sole supervision of and immediate super- intendence of the Asylum for Indigent Lunatics of the State, subject to the direction of the Board of Commissioners of State Institutions. Sec. 19. — Physician. The physician of the State-prison shall also be the physician for such asylum, and shall exercise such powers, in the matter of care of the inmates of such asylum, as may be prescribed by said Board of Commissioners. Acts of Floeida, 1887. Chapter 3706, Section 1. — Physicians of Asylum to Keep Record of Patients, etc. That it shall be the duty of the physician in charge of the insane asylum of this State to thoroughly investigate the history of patients, and upon careful diagnosis of same make a record thereof in a book of sufficient magnitude, which book shall be termed the " Physician's Book of Record " ; and such record shall contain the name of each person who may thus come imder his treatment, the name of the disease to be treated and the date of beginning treatment, and each day's prescriptions while under treatment ; which record shall be open for future reference by his successor, the cabinet officers, legislative committees, and all others interested. Acts op 1883. Chapter 3444, Section 1. — Fee and Mileage. That hereafter any practicing physician who shall be called in by the circuit judge to testify on an investigation as to lunacy or insanity of an indigent person who shall be alleged to be a lunatic or insane shall be paid the sum of five dollars and ten cents AI'PENDIX. G41 per mile by the State, out of appropri of tlie opinion from such preliminary incpiiries as they may make — and in making which they shall take the testimony of the informant, if they deem it necessary or desirable, and of other witnesses, if offered — that such course would probably be in- jurious to such person, or attended with no advantage, they may dispense with such l)erson. In their examination they shall hear testimony for and against such applica- 1ion, if any is offered. Any citizen of the county, or any relative of the person alleged to be insane, may appear and resist tlie application, and the parties may appear by counsel if they elect. The commissioners, whether they dispense with the presence before them of such person or not, shall appoint some regularly practicing physician of the county to visit such person and make a personal examination touching the truth of the information and the mental condition of such person, and forthwith report to them theroon. Such physician may or may not be one of their own number ; and the physician so appointed and acting shall certify, under his hand, that he lias in pursuance of his appointment made a careful personal examination as required, and that on such examination he finds tlie person in question insane, if such is the fact ; and, if otherwise, not insane ; and in connection with his examination the said physi- cian shall eiideavor to obtain from the relatives of the person in question, or from others who know the facts, correct answers, as far as may be. to the interrogatories hereinafter required to be ])i'opounded in such cases ; such interrogatories and answers to be attached to his certificate. Sec. 1401. — On return of tlie physician's certificate the commissioners shall, as soon as practicable, conclude tlieir investigation, and shall fiml wliether the person alleged to be insane is insane ; whether, if insane, a fit subject for treatment and cus- tody in the hospital ; whether the alleged settlement of such person is in their county, and, if not in tlieir county, where it is, if ascertained. If tliey find that sucli person is not insane they shall order liis immediate discharge, if in custody. If they find such person insane and a fit subject for custody and treatment in the hospital (they sliall order said person to be committed to the hospital, unless said person so found to be insane [or some one in his or her behalf] shall appeal from the finding of the said commissioners) they shall forthwith issue their warrant and a duplicate thereof^ 646 APFEXDIX. stating siie]i finding, witli the settlement of the person, if found ; and, if not found, theii" information, if any, in regard thereto, authorizing the superintendent of the hosxjital to receive and keej) such i^erson as a patient therein : such warrant and duj)licate, "with the certificate and finding of the physician, shall be delivered to the sherrff of the county, who shall execute the same by conveying such person to the hospital, and delivering him, with such duplicate and physician's certificate and find- ing, to the superintendent thereof. . . . Sec. 1424. — Any patient who is cured shall be immediately discharged by the superintendent. Upon such discharge the superintendent shall fm-nish the patient, unless otherwise supplied, with suitable clothing and a sum of money not exceeding twenty dollars, which shall be charged with the other expenses in the hospital of such patient. The relatives of any patient not susceptible of ciu-e by remedial ti'eatment in the hospital, and not dangerous to be at large, shall have the right to take charge of or remove such jDatient on consent of the Board of Trustees. In the intermediate meetings of the board the consent of two trustees shall be sufficient. G-EXERAL Statutes of Kaxsas, 1889. Sec. 260 {Qim).— Government. The government of insane asylimis of the State shall be vested in the Board of Trtistees of the institutions for . . . insane. Sec. 261 (61S7).—Apj)lication. The Board of Trustees shall designate the superintendent of one of the insane asylums, to whom all applications for the admission of insane persons shall be made, and who, under such rules as may be made by the Board of Trustees, shall designate to which asylum each applicant shall be admitted. . . . Sec. 263 {61S9).— Medical and Executive Officer. The supeiTntendent shall be the executive officer of the asylum and shall have control of all the aft'airs of the asylum, subject to the direction of the Board of Trus- tees. . . . He shall make to the Board of Trustees at least semi-annual reports show- ing the movements of the population and the operations of the asylum dui-ing the period embraced therein; and at the close of the biennial period he shall report in detail the conditions of the asylum and all of its concerns. Sec. 266 (6192). — Abstract of Correspondence. A full absti'act of all correspondence relating to the admission of patients, their treatment, and all other matters of an official natui-e and the replies thereto, shall be kept by the superintendent. He shall also cause to be kept a complete record of each ease and the treatment thereof, and prescription-book, with the date when it was appointed and administered, and such other records as may be necessary to give the board and the public a ftill knowledge of all prescriptions and business of the medical department. State of Kentucky, Statutes, 1881. Chapter 73, Section 4. — Officers of the Asylum. There shall be for each asylum a medical superintendent, who shall be a skillful physician, and a steward ; and for the Eastern Kentucky Asylum a first and a second assistant physician ; and for the Central Kentucky Asylum one assistant physician. These officers shall reside in the asylum. . . . Sec. 5. — Duties of Medical Superintendent. A medical superintendent shall have general management, supervision, and con- trol of patients and the asylum, subject to the regulations of the Board of Commis- sioners, and shall devote his entire time thereto. He shall keep a register of all Arj'KXDix. G47 patients, sliowing their names, ages, residences, dates of reception and discharge or death, by wliose antliority received, and whether they are ])ay-patients or paupers. The superinteiuleiit sliall jii)pi)iut all Hueh other inferior oOieers and employees (not otherwise provided for in this act) as he may deem necessary for the proper niaiiaj^'ement of Hie institution ; and he may remove any of them at pleasure and till tiieir places with others. Sec. 9. — I'reiioncc of the Person Xeccssciri/. No inquest shall be held unless the person charged to be of unsound mind is in the court and personally in the presence of a jury. The personal presence of the person charged shall not be dispensed Avitli xmless it shall appear by the oath or affidavit of two pliysicians that they made personal examination of the individual charged to be of unsound mind, and that they verily believe him to be an idiot or lunatic, as the ease may be, and that his condition is such that it may be unsafe to bring him into court. Sec. 14. — Discharge of Patients. No private patient who has not been found to be insane by regular inquest shall be received into either of the State asylums. Nor shall any patient be discharged as •cured, or delivered to the custody of friends, whose friends have placed him in the asylum, but by permit of the superintendent and commissioners. Any cured patient who was committed to the asylum while in custody of the law upon a criminal charge shall be delivered to the keeper of the penitentiary or to the jailer of the county, as the case may require. A ciu'ed pauper before being discharged shall have a good suit of clothes and be furnished with money enough to pay his ti'aveling expenses back home, not exceeding twenty dollars. Sec. 20. — Bcjwrt of Superintendent and Board. The superintendent and the Board of Commissioners shall, on or before the 1st of November of each year, make a report to the governor of the condition of the asylum in their charge, . . . number and names of patients (distinguishing pauper from pay patients and certifying the place from which they came), the number received and discharged each year, with such other facts and suggestions they may deem important, which report the governor shall communicate to the legislature at its next regular session. Statutes of Louisiana, 1876. Sec. 1768. — Lunatics — Hoiv Admitted. Whenever it shall be known to the judge of a district or parish court, by the peti- tion on oath of any individual, that any lunatic or insane jierson within his district ought to be sent or confined in the insane asylum of this State, it shall be the duty of said district or parish judge to issiie a warrant to bring before him said lunatic or in- sane person, and after inquiry into all the facts and circumstances of the case, if in his opinion he oiight to be sent or confined in said asylum, he shall make out his war- rant to the sheriif of the parish, commanding him to convey the lunatic or insane person to the insane asylum. ... Sec. 1776. — Examination hi/ PJiysician. The physician of the asylum shall professionally examine the hmatic or insane person sent to the asylum by the authority of the district or parish judge, and if in his opinion said person is only feigning insane, being a person charged with felonious crime, he shall report to the board, who shall investigate the facts, and if in the judg- ment of the majority said person shall not be admitted as an inmate of the asylum, the president of said board shall cause said person feigning insanity, and who had been previoiisly committed to prison for a crime, to be confnuMl in Hie parish jail, and shall immediately inform the president of the police of the parish, or a proper author- it_v in the parish of Orleans, where the rejected person has his domicile, of the fact and the reason of his rejection ; and the provisions of this section shall also apply to such persons charged with a crime who afterward recover and become sane in said iisvlum. (348 APPENDIX. Acts of Louisiana, 1888. Sec. 1. — Postal Bights of Inmates. Be it enacted by tlie General Assembly of Louisiana, that henceforth each and every inmate of each and every insane asylum, both public and private, in the State of Louisiana, shall be allowed to choose one individual to whom he or she may write when and whatever he or she desires, and over these letters to this individual there shall be no censorship exercised or allowed by any of the asyhun officials or employees, but their post-office privileges shall, so far as this one individual is concerned, he as free and unrestricted as are those of any other resident or citizen of the State of Louisiana, and shall be under the protection of the same postal laws ; and each and every inmate shall have the right to make a new choice of this individual every three months if he or she so desires. And it is here made the duty of the superintendent to fiu'uish each and every inmate of every insane asylum in this State, either public oi- private, with suitable material for writing, inclosing, sealing, stamping, and mailing letters, sufficient at least for the writing of one letter a week, provided they request the same, unless they are otherwise furnished with such material ; and all such letters shall be dropped by the writer thereof, accompanied by an attendant when necessary, into a post-office box of the State at the insane asylum and kept in some place easy of access to all patients. . . . Statutes of Maine, 1883. Sec. 1. — Government of the Asylum. The government of the Maine Insane Hospital is vested in a committee of six trustees, one of whom shall be a woman. . . . Sec. 4. — TJie Trustees may Examine and Discliarge Patients. There shall be a thorough examination of the hospital monthly by two of the trustees, quarterly by three, and annually by a majority of the full board ; and at any other time when they deem it necessary or the superintendent requests it. At each visit a written account of the state of the institution shall be drawn up by the visitors, recorded, and presented at the annual meeting of the trustees, at which meeting they, with the superintendent, shall make a particular examination of the condition of each patient, and discharge any one so far restored that his comfort and safety and that of the pulalic no longer require his confinement. . . . Sec. 7. — Duties and Powers of the Superintendent. The superintendent shall be the physician, reside constantly at the hospital, have general superintendence of the hospital and grounds, receive all patients legally sent to the hospital, unless the number exceeds its accommodation, and have charge of them, and control of all persons therein, subject to the regulations of the Board of Trustees ; and annually on the last day of November report to the trustees the condi- tion and prospects of the institution, with such remarks and suggestions relative to its management and the general subject, of interest, as he thinks will promote the cause of science and humanity. Sec. 29. — Rules should be Kept Posted. The superintendent shall keep posted, in conspicuous places about said hospital, printed cards containing the rules prescribed for the government of the attendants in charge of patients. Sec. 34. — Certificate of Physicians. In the case of preliminary proceedings for the commitment of an insane person to the hospital, the evidence and certificate of at least two respectable physicians, based upon due inquiry and personal examination of the person to whom insanity is im- puted, shall be required to establish the fact of insanity, and a certified eopj^ of the physicians' certificate shall accompany the person to be committed. APPENDIX. G4t) Sec. 36. — Postal Rujlits of the Inmates. The names of the Committee of Examiners and the post-office address of each shall he kept posted in every ward of the hospital, and every inmate shall be allowed to write when and whatever he pleases to tlieni, or either of them, unless otherwise ordered by a majority of the committee in writing, wliich order shall continue in force until countermanded in writing by said comnuttee. For this purpose every patient not otherwise ordered as aforesaid shall be furnished by the superintendent, on re- quest, with suitable materials for writing, inclosing, and sealing letters. Tlie super- intendent shall provide, at the expense of the State, securely locked letter-boxes, easily accessible to all inmates, to be placed in the hospital, into wldcli such letters can be dropped by the writer. No officer, attendant, or employee of the hospital shall have tlie means of reaching the contents of these boxes, but the letters in them shall he collected weekly by some member of the committee, or by such person as the com- mittee authorizes for the purpose, who shall prepay such only as are addressed to some of the committee, and deposit them in the post-office without delay. Laws of IMaryland, 1888. Sec. 1. — When any person is alleged to be a lunatic or insane, the Circiut ■Court of the county in which such person may reside, or a criminal court of Baltimore (if such person reside in the city of Baltimore), shall cause a jiuy of twelve good and lawful men to be impaneled forthwith, and shall chai'ge the said jiu-y to inquire whether such jjerson is insane or lunatic ; and if found so it shall be the duty of the court to cause such person to be sent to the almshouse of the county, or to a hospital, ■or to some other place better situated, in the judgment of the court, for his condition, there to be coniined at the expense of the county or State until he shall recover and be discharged in due course of law. . . . Sec. 26. — The superintendent or other officer or keeper of any institution, public, ■corporate, or private, or almshouse, where the insane may be kept, shall be required to keep a record of all patients in such form as the commissioners shall direct ; also a record in which shall be entered the incidents and accidents that may occiu- ; also the number and kinds of restraints used, with details of them, to be reported to the commissioners. Sec. 30. — The Board of Managers or superintendent of any institution, public, corporate, or private, or almshouse, which may be duly authorized to hold iu custody any insane person in accordance with the law, may appoint one or more attendants or other employees of such places, as policeman or policemen, whose duty it shall be, under the orders of said superintendent or manager or keeper, to arrest and return to such asylum, or other institution for the treatment of the insane, or insane persons who may escape therefrom. Sec. 31. — No persou shall be put or confined as a patient in any institution, piib- lic, corporate, or private, or almshouse, or other house for the care and custody of the insane or idiotic, except upon the rendering of a certificate of two qualified physicians, made within one week after the examination by them of said alleged hmatic, and set- ting forth the insanity or idiocy of such person, and the reason for such opinion. ... Sec. 33. — The superintendent or other officer of any asylum or other institution where the insane are kept in custody or received for treatment, whether public, cor- porate, or private, or almshouse, shall within ten days after the reception of such patient or person make, or cause to be made, a description of such case in a book kept exclusively for the purpose ; they shall also make entries from time to time of the mental condition of such patient or person so confined. Sec. 35. — Every person confined in such place as hereinbefore mentioned shall be furnished at all times with paper, envelopes, stamps, lien and ink, or pencil ; shall at all times have access for correspondence with the L\macy Commission, and some one other person wliom such lunatic may designate every month, under seal, which com- munication shall be forAvarded by the officer, superintendent, or keeper who may be in charge of such person or place. ... Acts of Massachusetts, 1882. Chapter 87, Section 11. — Jitdgcs may Commit Insane Persons to the State Hospitol. A judge of the Supreme Judicial Court or Superior Court of any coimty, or a judge of a probate court, or of a police or district or nnmicipal court within this 650 APFEyDix. county, may commit to either of the State lunatic asylums any insane person. Tvhen residing or being in said county, who in his opinion is a proper, subject for its treat- ment or custody. Sec. 12. — Xo Person to he Committed to any Hospital icithoiit Order of the Judge. Except when otherwise specially provided, no person shall be committed to the limatic hospital or other receptacle for the insane, public or private, without the order or eertiiicate therefor signed by one of the judges named in the preceding sec- tion, said person residing or being within the county as herein proAided. Such order or certificate shall state that the judge finds the person committed is insane and is a fit person for the treatment of the insane asylum. The said judge shall see and examine the person alleged to be insane, or state in his final order why he did not deem it necessary or advisable to do so. . . . Sec. 13. — Certificate of two Fliysicians. No i^erson shall be committed unless, in addition to the formal testimony, there has been filed with the judge a certificate signed by two physicians, each one of whom is a graduate of some legallj^ organized medieal college and has practiced three years in the State, and neither of whom is connected with any hospital or other establish- ment for treatment of the insane. Each must have personally examined the person alleged to be insane "n^ithin five days of signing the certificate, and each shall certify that in his opinion said person is insane and a j^roper subject for treatment in the insane hospital, and shall specify the facts on which his opinion is formed. A copy of the certificate, attested by the judge, shall be delivered by the oflicer or other person making the commitment to the superintendent of the hospital or other place of commitment, and shall be filed and kept with the order. Sec. 15. — Statement regarding Insane Person to be Filed icitJi the Judge — Duty of the Superintendent. Upon every application for the commitment or admission of any insane person to a hospital or asylum for the insane there shall be filed with the api:ilication, within, ten days after the commitment or admission, a statement in respect to such person, showing, as near as can be ascertained, his age, birthplace, exact condition, place, and occupation ; the supposed cause and duration and character of his condition, whether mild, Adolent, dangerous, homicidal, suicidal, parahi:ic, apoplectic ; the present symptoms of insanity in the person or his family ; his habits in regard to tem- perance ; whether he has been in a limatie asylum or hospital, and, if so, what one, when, how long; and, if the patient is a woman, whether she has borne children, and, if so, what time had elapsed since the buth of the youngest ; the names and addresses of his father, mother, children, brother, sister, or others next of kin, not exceeding ten in number and over eighteen years of age, when the names and addresses of such relatives are known by the person or persons making such applica- tion, together with any fact showing whether he has or has not a settlement, and. if he has a settlement, in what place ; and if the applicant is unable to state any of the above particulars he shall state his inability to do so. The statement, or a copy thereof, shall be transmitted to the superintendent of the hospital or asylum, to be filed with the order or application for admission. The superintendent shall, within two days of the time of admission or commitment of the insane person, send, or cause to be sent, notice of said commitment, in wi-iting, by mail, postage prepaid, to each of said relatives, and to any other two persons whom the person committed shall designate. Sec. 26. — Persons Violently Insane may he Bcceived at the Hospital without Warrant of Commitment. The superintendent or keeper of a hospital, including the McLean Asylum at SomerAdlle, may receive into his custody, and detain in such hospital or asylum for a period not exceeding five days, without an order of the judge as provided in section 2, any person as insane whose case is duly certified to be one of violent and dangerous insanity and emergency by two physicians qualified as in section 13. In addition to such certificates an application signed by one of the selectmen of the town, or by one of the aldermen of the city, in which such insane person resides or is found, shall be left with the superintendent of the hospital or asylum in Avhich the insane person is APPENDIX. CGI received, and sTich application shall contain tli(> statement in respect to such insane person vvliicli is required by section 15, and a further statement that the case is one of violent and dangerous insanity. Skc. -9. — Xotice U) be (Uroi to llic Bodvd of IlcalUi, LiiitKcii, on the nomination of the medical superintend- ent, a steward and a chaplain; and also, in a like manner, an assistant medic;il superintendent and necessary assistant physicians. All medical officers shall reside at the asylum. , . . 652 AFPESDIX. Sec. 12. — Powers and Duties of the Medical Superintendent, The medical superiniendent shall be the chief executive officer of the asyliim. He shall have the general superintendence of the buildings, gi'ounds, and farm, together with the furnitui'e, fixtures, and stock ; and the direction and control of all persons therein, subject to the by-laws and regulations established by the trustees. He shall daily ascertain the condition of all j)atieuts, and prescribe for their treatment in the manner directed in the by-laws. He shall have the nomination of his co-resi- dent officers, with power to assign them to their respective duties, subject to the by-laws ; also to appoint, with the apj^roval of the trustees, such and so ma,ny other assistants and attendants as he may think necessary and proper for the economical and efficient performance of the business of the asylum, and to prescribe their several duties and places, and fix, with the approval of the trustees, their compensation, and to discharge any of them at his will and discretion ; but in every case of discharge he shall forthwith record the same, with the reasons of discharge, under a proper head in one of the books of the asylum. He shall also have the power to suspend until the next meeting of the trustees, for good and sufficient cause, a resident officer ; but in such case he shall forthwith give written notice of the fact, with its cause and cir- cumstances, to one of the trustees, whose duty thereuj)on shall be to call a special meeting of the board to provide for the exigency. He shall also, fi-om time to time, give such orders and instructions as he may judge best calculated to insure good conduct, fidelity, and econouiy in every department of labor and expense ; and he is authorized and enjoined to maintain well-directed discipline among all who are em- ployed by the institution, and to enforce direct compliance with such instructions and uniform obedience to all rules and regulations of the asylum. He is authorized and directed to use every proper means to fiu'nish employment to such patients as ma,v be benefited by regular labor suited to their capacity and strength. He shall further cause full and fair accounts and records of all his doings and the entire business and operations of the institution to be kept regularly from day to day, in books ijro^ided for that purpose, in the manner and to the extent prescribed in the by-laws ; and he shall see that all such accounts are fully made up to the last day of September imme- diately preceding the meeting of the legislature, and that the principal facts and results, with his reports thereon, be at the time presented to the trustees. It shall be the duty of the medical superintendent to admit any member of the Board of Trustees in every part of the asylmn, and to exhibit to him or them on demand all the books, papers, and accoimts and writings belonging to the institution or pertaining to its biisiness, management, discipline, or government ; also to fiu'nish coijies of abstracts and reports whenever reqnii-ed by the board. The medical superintendent shall make, in a book kept for that purpose, at the time of reception, a minute with date of same, the name, residence, office, and occuxiation of the person, by whom and by whose authority each insane person is bi'ought to the asylum ; and shall have all the orders, warrants, requests, certificates, and other papers accompanying him forth- with filed. The assistant medical superintendent shall perform the duties and be sub- ject to the responsibility of the medical superintendent in his sickness or absence. Laws of 1889. Sec. 21. — Certificate of Admission of Patients — . . . Duty of Medical Superintendent to Notify Judge, etc. No person shall be admitted or held as a private patient in any asylum, public or private, or any institution, home, or retreat for the care or treatment of insane, except upon the certificate of two reputable physicians imder oath, appointed by the judge of Probate Court where such alleged insane person resides to conduct an examination, and an order from the said judge of tlie Probate Com-t setting forth that the said per- son is insane, and directing his removal to an asylum or institution for the care of in- sane ; no person shall be held in confinement in any siich asylum or institution for more than fourteen days without such certificate or order. Sec. 22. — Qualifications of Physicians Certifying to Insanity, etc. It shall not be lawful for any pliysician to certify to the insanity of any person for the purpose of securing his admission to an asylum, unless such physician be of repu- table character and gi-aduate of some incorporated medical college, a permanent resi- APPENDIX. Go'J tter lie or she wi'ites to this individual inmate; and all these letters bearing the iiulividiial writer's name on the outside he is requested to deliver, or cause to be delivered, any letter or writing to him or her 65-4 APPENDIX. directed, without opening or reading the same, or allowing it to be opened or read, iinless there is reason for believing the letter contains some foreign substance which may be used for medication, in which case the letter shall be required to be opened in the presence of a competent witness, and this substance shall be delivered to the superintendent, to be used at his discretion. Sec. 4. — Superintendent to Provide Registers and Stationery. It shall be the duty of the superintendent of each hospital or asylum for insane to furnish each assistant physician with a pocket-register of correspondence, in such way as the State Department of Corrections and Charities may prescribe, and to keep on hand some envelopes, j)aper, and postal cards, which shall be used for each correspondent. Such registers and stationery shall be furnished on requisition of the assistant physi- cians, and shall be paid for from the current expense funds of such institution. . . . Whenever any letter or postal card from any correspondent chosen under this act shall be delivered to any assistant physician by the superintendent, he shall delivei- the same to the inmate to whom it is addressed, without unnecessary delay, taking the receipt of said inmate therefor. Sec. 6. — Tlie Superintendent to Mail and Deliver Letters. ... It shall be the duty of the superintendent, upon receipt of such letters from the assistant physician, if he shall find that the said letter is addressed to a corre- spondent duly chosen imder this act, to place such letter, or cause it to be placed, in the United States mail without opening or reading the same. It shall be the duty of the superintendent to request the said correspondents to write their names on the outside of the letters sent by them to the inmates. The said superintendent shall deliver such letters to the assistant physician, to be given to the inmates to whom they are addressed, unless in the judgment of the said superintendent the receipt of such letters would be injurious to such inmates, in which ease they shall forthwith notify such correspondents that such letters are withheld, stating the reasons therefor, and recording the fact in the register of correspondence. No letter wi-itten by a corre- siDondent to an inmate shall be opened by any superintendent, unless he has reason to suspect that it contains such matter as ought not to be delivered to said inmate, in which case he shall record the fact that such letter has been opened, and the reasons therefor, in the register of correspondence. Sec. 7. — Inmates may Correspond iciih the Governor and the Secretary of the State Board of Corrections and Charity. . . . Each and every inmate of any hosisital for the insane in the State shall have the priAdlege of communicating in Avriting with the governor and the secretary of th& State Board of Corrections and Charities, in the same manner, under the same regu- lations, as with the correspondents chosen under this act. Chapter 14, Section 267. — Physician to Examine Alleged Insane Person. Upon the filing of information the court shall make an order directed to two (2) persons, one of whom at least shall be a duly qualified physician ; and such persons, in connection with the judge of probate, shall constitute a jury to examine the person alleged to be insane, and they shall ascertain the fact of sanity or insanity. Sec. 274. — When Discharged, Probate Court to be Notified. When any person who has been committed to the care and custody of the superin- tendent of the hospital by warrant of the Probate Court shall be discharged from such hospital, the superintendent shall, upon day of such discharge, send by mail to the judge of probate of the coimty i7i which siich warrant was issued a certificate signed by him, stating that the person has been discliarged from such hospital, and the date of such discharge, which certificate shall be filed in the Probate. Court. Code op Mississippi, 1880. Sec. 665. — The medical superintendent shall have power to appoint and re- move all subordinate oificcrs and employees allowed by the trustees, and he shall make, in a book kept for that purpose, at the time of reception, a minute with the .irrKXDix. G35 date of reception, with name, a{?e, sex, residence, office or occupation of the person, and by whom and by whose autliority each insane person is broujjlit to the asylum, and have all orders, warrants, requisitions, certificates, and otlier papers accompany- ing him or her carefully liled, and liave them copied in said book. . . . He shall ascertain the condition of the patients, and i)rescribe their treatment in the manner prescribed in the said by-laws; and he shall also be required to see that all the rules and regulations for the tliscipline and good govei-nment of the institution are i^roperly obeyed and enforced. Skc 6.59. — Any person being a lunatic and resident of the State of Mississippi shall be admitted into the asylum free of charge. ... Skc. 660. — It shall be the duty of the superintendent to admit into the asylum all persons ordered to be placed therein after an inquest of lunacy, in the due order of registration, if there be a vacancy in such asylum, on the presentation of a dvdy certi- iied copy of such order under the seal of Chancery Coiu-t, showing thereby admission of the patient to the asylinu. Sec. 661. — On application in behalf of any person being a lunatic and a resident of this State, for liis or her admission into the asylum, the superintendent and Board of Trustees may, if they think he or she ought to be admitted, receive him or her as a patient therein, even though no proceedings in lunacy have been instituted as hereinafter provided for. Sec. 663. — In case the friends or relations of any lunatic shall neglect or refuse to place him or her in said asylum, and shall permit him or her to go at large, it shall be the duty of the clerk of the Chancery Court of any county in which such lunatic may reside or be found going at large, on the suggestion, in writing, of any citizen of the county, to direct the sheriff, by writ of lunacy, to summon as soon as may be the alleged lunatic and six discreet persons of the comity in which such lunatic is going at large, to make inquisition thereto on oath, and the result of such inquisition to be returned to the said court forthwith ; and if the person said to be a lunatic shall be adjudged by such inquest, or a majoi'ity of them, to be insane, and one who should be confined therein, the said clerk shall order said sheriif to arrest said lunatic, and place him or her in said asylum if there be a vacancy, or, if there be no vacancy, to confine such lunatic in the county jail until room can be had in the liuiatic asylum. . . . Revised Statutes of Missouri, 1889. Sec. 471. — Superintendent's Duties. The superintendent shall be a physician of knowledge, skill, and ability in his profession, and have experience in the management and treatment of insane ; he shall not, while such superintendent, engage in the practice of his profession, but shall, to the exclusion of all other business, devote himself to the super\'ision and care of the asylum and its inmates. Before entering on the diities of his office he shall take an oath or affirmation that he will diligently, faithfuUj-, and impartially discharge all the duties required of him by the law. Sec. 473. — Patients — How Admitted and Discharged. Persons afflicted with any form of insanity may be admitted into the asylum when the superintendent deems it probable that their conelition can be improved by the care and treatment of the institution ; and any person may be dischai'ged by the superintendent whenever he may believe that the condition of such person cannot be improved by a longer stay in the asylum. Sec. 478. — Pan-puticnts — How Admitted. Pay-patients, or those not sent to the asylum by order of the eom-t, may be ad- mitted on such terms as shall be by this chapter, and the by-laws of the asylum, pre- scribed and regulated. Sec. 479. — Terms of Admission. Preparatory to the admission of such a patient the superintendent shall be fur- nished with a request. . . . stating Ids age and place of nativity, if knowni, his Cliris- tian and surname, place of residence, occupation, and degree of relationship, or any €56 AFPEXniX. <;ireiimstances of connection between Mm and the person requesting Ms admission ; and a certificate . . . dated AvitMn two months, nnder oath, signed br two physicians, of the fact of his being insane. Such person signing such request or certificate shall annex to Ms name his profession or occupation, and the township, county, and State of residence, tmless these appear on the face of the document. Before any probate patient shall be received into the asylum there shall be produced to the superintendent a receipt from the treasurer of the asylum, acknowledging the payment to him of at least thirty days' charge in advance, and sufficient bond to the said treasurer condi- tioned with the obligees to secui'e the payment of the charges incun-ed in behalf, on account, of said patient. . . . No board constituting thirty days' payment shall be refimded if a patient making such payment shall be taken away within the period, uneured and against the consent of the superintendent. Chapter 86, Section 5513. — On Information — Probate Court to Inquire as to Sanity. If any information in waiting be given to the Probate Court that any person in its county is an idiot, lunatic, or person of unsound mind, and incapable of mahaging Ms affairs, and pray that an inquiry thereinto be had, the coui-t, if satisfied that there is good cause for the exercise of its jurisdiction, shall cause the facts to be inquired into by a jmy. Sec. 5550. — To he Discharged — JVIten. If it be found that such person has been restored to his right mind, he shaU be discharged from the care and custody, and the guardian shall immediately settle Ms accounts and restore to his person the things remaimng in his hands belonging or pertaining to him ; and if it be found that such person has not been restored to his right mind, the person at whose instance the inquiry was had may, in the discretion of the coui't, be required to pay the cost of proceeding. Statutes of Montana, 1887. Sec. 1215. — Examination of Person Alleged to he Insane. From and after the passage of this article it shall be the duty of the probate judge, or, in Ms absence or incapability to act, the chairman of the Board of Cormty Commissioners of the several coimties of this Territory, upon the application of any person under oath, setting forth that any person by reason of insanity is unsafe to be at large or is suffering imder mental derangement, to cause said person to be brought before him, at such time and place as he may direct ; and the said judge or commis- sioner shall also cause to appear, at the same time and place, a jui-y of three persons of his county, one of whom shall be a licensed practieijig jjliysician, who shall proceed to examine the person alleged to be insane ; and if such jury after careful examination shall certify upon oath that the charged is a lunatic, and the said judge or commis- sioner is satisfied that siicli person by reason of insanity is unsafe to be at large, or is incompetent to pro'S'ide for his or her own proper care and sujiport, and has no prop- erty available for that purpose, and has no kindred in the degree of husband or wife, father or mother, children, or brother or sister, li^-ing within the Territory, of suffi- cient means and ability- to pro^^ide for such care and maintenance, or if he or she have kindred within the Territory and such kindred fail or refiise to properly care for and maintain such insane person, such judge or county commissioner shall make out a duplicate warrant reciting such facts, and place it in the hands of the sheriff of said coimty, who shall immediately, in compliance therewith, have the person or persons therein named apprehended, and deliver him or her or them to the director aforesaid, at the place designated in the notification. . . . Sec. 1227. — Inmates mai/ he Discharged upon Beport of Physician. The governor shall direct and have discharged fi'om the insane asylum any of the inmates thereof at any time when, from the wi'itten report to him by the physicians in charge of said asylum, or either of them, or fi-om any lahysician who shall be appointed to Aisit and examine said institution, he believes such discharge should be granted; provided that the report upon which he may act shall be filed and kept in his hands. APPENDIX. 657 Sec. 1230. — Inmates of an Jsijlum may Choose Confidential Correspondent. . . . Each and every inmate of each and eveiy asyhim, both public and private, shall be allowed to choose one individual from the outside world, to whom he or she may write when and whatever he or siie desires, and over these letters to this indi- vidual there shall bo no censorship exercised or allowed by any ojie of the asylum officials or employees, but their post-office rights so far as this one individual is con- cerned sliall be as free and unrestricted as those of any other resident or citizen of tlie Territory of Montana, and sliall be under the protection of the same postal laws ; and each and every inmate sliall have tJie right to make a new choice of this individunl party every three months if he or she desires to do so. And it is here made the duly of the superintendent to furnish each and every inmate of every insane asylum in this Territory, either public or private, with suitable material for writing, inclos- ing, sealing, stamping, and mailing letters, sufficient at least for the writing of one letter a week, provided they request the same, unless they are otherwise furnished with such materials ; and all such letters shall be dropped by the writers thereof, accompanied by an attendant, into the post-office box i^rovided by the deimrtment at the insane asylum and kept in some place easy of access to all the patients ; the attendant is required in all cases to see that this letter is directed to the patient's correspondent, and if it is not so directed it must be held subject to the superin- tendent's disposal ; and the contents of this box shall be collected once every week by an authorized jserson from the Post-office Department, and by him placed in the hands of the United States mail for delivery. Sec. 1231. — Lists of Correspondents to he Eegistered and Posted. That it is hereby made the duty of the superinj;endent to keep registered and posted in some public place at the insane asylum a' true copy of the name of every individual chosen as an inmate's correspondent, and by whom chosen ; and it is hereby made the duty of the superintendent to inform each of the individuals of the name of the party choosing him or her, and to request him or her to wi"ite his or her name on the outside of the envelope of every letter he or she writes to this individual inmate ; and all these letters bearing individual writers' names on the outside he is requested to deliver, or cause to be delivered, any letter or writing to him or her directed, without opening or reading the same, or allowing it to be opened or read, unless there is reason for suspecting that the letter contains some foreign substance which might be used for medication, in which case the letter shall be required to be opened in the presence of competent witnesses, and this substance shall be delivered to the superintendent, to be used at his discretion. Nebraska Compiled Statutes, 1887. Sec. 2. — Post-office Privileges of Inmates. . , . Henceforth there shall be no censorship exercised over the correspondence of the inmates of the hospital for the insane in this State, but their post-office rights shall be as free and unrestricted as are those of any resident or citizen of this State, and be under the protection of the same postal laws, and every inmate shall be allowed to write when and whatever he or she desires to any person he or she may choose. And it is hereby made the duty of the superintendent to furnish each and every in- mate of each and every insane asylum in this State with suitable material, at the expense of the State, for writing, inclosing, sealing, stamping, and mailing letters, sufficient for Writing at least one letter a week, provided they request the same, unless they are otherwise furnished with such material. . . . Sec. 11. — Duties and Poirer of the Siq^erintendent. The superintendent of said institution shall be a physician of acknowledged skill and ability in his profession, and be a graduate of a regular medical college. He shall be the chief executive officer of the hospital, and shall hold his office for the term of six years, unless sooner removed by the governor, for malfeasance in office, or other good and sufficient cause. He or the assistant physician must be in daily 658 AFPEXDIX. .attendanee at tlie hospital, and in no instance must they both be absent at the same time. Before entering upon the duties of his office he shall take and prescribe an •oath for the faithful and diligent discharge of the duties required by law. He shall have the entii'e control of the medical, moral, and dietetic treatment of patients, and shall see that the several officers of the institution faithfully and diligently discharge their respective duties. He shall employ attendants, servants, nurses, and such per- sons as he may deem necessary for the efficient and economical administration and government of the asylum. Sec. 21. — Ai^plication for Admission to tJie Hospital. Application for admission to the hospital must be made in vn-iting in the natm'e of information validiiied by af&davit ; such information must allege that the person in whose behalf the application is made is believed hj the informant to be insane and a fit subject for custody and treatment in the hospital ; that such person is found in the county and has an alleged settlement therein, if such is known to be the fact ; and, if such settlement is not in the county, where it is, if known, or where it is believed to be, if the informant is advised on the subject. Sec. 12. — Investigation of tlie Commissioners. On the filing of any information as above provided, the commissioners shall at once take steps to investigate the grounds of the information. For this purpose they may reqmre that the person for whom such admission is sought be brought before them, and that the examination be had in his or her presence. . . . The commission- ers, whether they decide to dispense with the presence of such person or not, shall appoint some legally practicing physician of the county to visit or see such person, and make a personal examination touching the truthfulness of the allegation in the information, and adjudge the actual condition of such person, and forthwith report to them thereon j and said physician may or may not be of their own number; and the physician so appointed and acting shall certify in his own hand that he has, in pui'- suance of his appointment, made a careful personal examination as required ; and that on such examination he finds the person in question insane, if such is the fact ; and, if otherwise, not insane ; and in connection with his examination the said physician shall endeavor to obtain from the relatives of the person in question, or from others who know the facts, correct answers so far as made in the interrogatories hereinafter required to be propounded in such cases, which interrogations and answers shall be attached to the certificate. Statutes op Nevada, 1889. Chapter 39, Section 1. — Whenever by reason of absence of the district judge of the coTinty an insane i^erson cannot be brought before him for examination, he may be taken before the county clerk of such county, and thereupon said county clerk shall be vested with the power to hold such examination and discharge such jDerson or commit him to the insane asylum in the same manner as may be done by the district judge. General Statutes, 1885. Sec. 1457. — District Judge to Examine Insane Person — Physician to Attend. The district judge of any judicial district in this State shall, tipon application under oath, setting forth that a person by reason of insanity is dangerous to be at large, cause any person to be brought before him, and he shall summon to appear, at tlie same time and place, two or more witnesses having had frequent intercourse with the accused dm-ing the time of alleged insanity, who shall certify under oath as to conversation, manners, and general conduct upon which said charge of insanity is based ; and he shall also cause to appear before him at tlie same time and place two gi'aduates in medicine, before whom the district judge shall summon a jury, and if after careful hearing of the case and a personal examination of the alleged insan.-' person the said phy.sieians shall certify on oath that the case is of recent or curable character, or that the said insane person is of a homicidal, suicidal, or incendiary A I' P EX D IX. G59 ■ilisiiosition, or if from any otlier violont syinptojiis tlic said insane person would be dangerous to liis or lier own life, or to the lives and property of tlie eonnnuiiity in wliicii he or she may live; and if said pliysieians shall also certify to the name, age, nativity, residence, occupation, length of time in tliis State, apparent cause and class of insanity, duration of disease, and present condition as nearly as can be ascertained by inquiry and examination ; and if tlie district judge slialL be satisfied that tlie facts in tlie examination establish tlie existence of insanity in tlie person of the accused, of a recent or curable nature, or of a homicidal, suiciihil, or incendiary eliaracter, or from tlie violent symptoms the said insane person would be dangerous to his or her own life, or to tlie lives and property of others, to be at large, he sliall direct the sheriff or some suitable person to convey to the eapitol of the State and place such insane person in eliarge of tlie secretary of tlie State, and shall transmit duplicate copies of complaint and commitment and pliysicians' certificates, which shall also be in form as furnished to the judge, to the secretary of the State. New Hampshire Laws, 1889. ■Chapter 18, Section 6. — Onli/ Fanper Insane in Countij Amjlunts — Beports of County Superintendent. No person otlier than a pauper shall be admitted into any county asylum, and the superintendent of every asylum or other place in this State where insane persons are confined shall, within three days after the commitment of any person, notify the board of such confinement upon a blank furnished for that pm-pose ; and the said superin- tendent shall at all times furnish such information, regarding the insane in Ms charge as the State board may request. 1878. — Chapter 10, Section 12. — Persons Dangerous to he Committed to the Asylum. If any person is in such condition as to render it dangerous that lie should be at large, the judge of probate, upon petition of any person and such notice to the select- men of the town in which such insane person is, or to his guardian, or to any other person as he may order — which petition may be filed, notice issued, and a hearing had in vacation or otherwise — may commit such insane person to the asylum. Sec. 18. — Certificate of tiro Pliysicians Pequired to Commit. No person shall be committed to the asylum for the insane, except by order of ■court or the judge of probate, without a certificate of two respectable physicians that such person is insane, given after a personal examination made within one week of committal ; and such certificate shall be accompanied by a certificate of the judge of the Supreme Court, or of the court of probate, or mayor or chairman or selectman, testi- fying to the truthfulness of the signatures of the signers. Sec. 25. — Superintendent may Furnish Stationery, Paper, and Transmit Letters to Trustees. It shall be the duty of the superintendent to furnish stationery to any patient who may desire it, and transmit any letter such patient may address to the Board of Trus- tees to such member as said board shall have designated to receive such correspond- ence, and all such letters shall be promptly transmitted without interception. Laws op New Jersey, 1889. Chapter 168. — Superintendent or Warden to Send a List of Patients Chargeable to the County. ... It shall be the duty of the superintendent or warden of the respective State asylums for the insane in this State, at which patients are supported at the expense of any county of this State, to make out under oath and send to the clerk of the Board of Chosen Freeliolders of each and every county supporting patients at said asylums, at least three days before the meeting of the said Board of Freeholders, at which a quarterly bill of said asylum shall be presented, a regular and quarterly statement giving the names of all patients at said asylum at the expense of the coimty for whicli 5G0 APFEXDIX. said statement is made, wlio have been at said asylum during the last preceding quar- ter, which statement shall also contain the dates of admission of the respective patients, the township from which they came, the days of discharge of any who have been discharged, the date of death of any who have died, and the dates between which they have been away on a visit or otherwise during the quarter. Tkenton Asylum, 1886. Sec. 1. — Admission of Patients. . . . No person shall be admitted into the asylum as a patient except upon the order of some court or judge aiithorized to send patients, without lodging with the superintendent — first, a request under the hand of the person by whose direction he is sent, stating his age and place of nativity, if known, his Christian and surname, place of residence, occupation, and degree of relationship, and other circumstances of connection between him and the person requesting his admission ; and second, a certificate dated within a month, under oath, signed by two respectable physicians, of the fact of his being insane. Each person signing svich request or certificate shall annex to his name his profession or occupation, and the townshij) and county and State of his residence, unless these facts appear on the face of the documents. Sec. 7. — Duties and Powers of Physician. The superintendent shall be the chief executive oflicer of the asylum. He shall have the general superintendence of all the buildings, grounds, and farm, with their furnitiire, fixtures, stock, and the direction and control of all persons therein, subject to the laws and regulations established by the managers. He shall daily ascertain the condition of the patients, and prescribe their treatment in the manner prescribed in the by-laws. He shall appoint, with the approval of the managers, so many assistants and attendants as he may think proper and necessary for the economical and efficient performance of the business of the asylum, and prescribe their several duties and places, and fix, with the managers' approval, their compensation, and discharge any of them at his sole discretion ; but in every case of discharge he shall forthwith reeoi"d the same, with the reasons, under the proper heading in one of the books of the asylum. He shall also have the power to suspend until the next meeting (monthly) of the managers, for good and sufficient cause, any resident officer ; but in such case he shall give written notice to the effect, with its cause and circumstances, to one of the managers, whose duty thereupon shall be to call a special meeting of the board to provide for the exigency. He shall also, from time to time, give such orders and in- structions as he may judge best calculated to insiu-e good conduct, fidelity, and econ- omy in every department of labor and expense ; and he is authorized and enjoined to maintain salutary discipline among all who are employed bj^ the institution, and to enforce strict compliance with such instructions and uniform obedience to all rules and regulations of the asylum. He shall cause a fixll and fair account and record of all his doings, and of the entire business and operations of the institution, to be kept regularly from day to day in a book provided for that purpose, in the manner and to the extent prescribed in the by-laws ; and he shall see that all such accounts and records are fully made up to the last day of December in the year, and that the principal facts and results, with reports thereon, be presented to the managers imme- diately thereafter. The assistant physician shall pei-form his duties and be subject tO' the responsibilities of the superintendent in his sickness or absence. Sec. 36. — Discharge of Patients. . . . The managers, upon the superintendent's certificate of complete recovery, may discharge any jjatient except those under criminal charge or liable to be removed to prison ; and they may send back to the poorhouse or township of the county from whence he came any person admitted as dangerous who has been two years in the asylum, upon the superintendent's certificate that he is harmless and will probably continue so, and not likely to be improved by further treatment in the asylum ; or, when the asylum is full, upon the certificate that he is manifestly incurable and can probably be rendered comfortable at the poorhouse. They may also discharge and de- liver any patient, except one under criminal charge as aforesaid, to his relatives or friends who will undertake, with good and approved securities, for his peaceable be- havior, safe custody, and comfortable maintenance without further public charge. Ill J IT EX nix. CCi Sec. 21. — rrocccdings ivhcn LiDiaticn are Dangerous if at Large. That it shall be and may be lawful for any two justices of the peace of the county 111 which any lunatic, furious, mad, or dangerous, if permitted to go at large, shall be found, by warrant under tlieir liauds and seals, to direct tlie Overseers or Overseer of the Poor of the city or township in wliich such lunatic or mad person may be found, to cause such person to be apprclicndcd and kept safely locked up, and chained if necessary, in some secure jilace within such city or township or within tlie county within which said city or township shall be situated, as sucli justices shall by their warrant appoint, in case the legal settlement shall be in the city or township in the said county. New Mexico, 1884. Sec. 1324. — Judge may Issue a Commission — When. It shall be lawful for any district judge in this Territory to issue a commission, in term or vacation time, in the nature of a writ de Iiinalico iiit/uircudo, to inquire into the lunacy or habitual drunkenness of any person within tJiis Territory, or having real or ])ersonal estate therein. Such commission shall issue in the county wherein he last had his residence, or in which his property is situated, and shall be executed therein. Sec. 1327. — Order made to Court. It shall be the duty of the court, at the time of granting any application as afore- said, to make such order respecting notice of the execution of the commission to the party with respect to whom such commission shall be issued, or to some of liis near relations or friends who are not concerned in the application, as the said court shall deem advisable. Sec. 1328. — Jury of Inquest. It shall be lawful for the commissioner or commissioners to direct an order to the sheriff, requiring him to summon not less than, nor more than twelve persons upon the inquest, as the circumstances to them may seem to require. Sec. 1329. — I)uiuisition — JThcn Held. If the court shall be of the opinion that the person with respect to whom proceed- ings are instituted has no estate, or not suflicient to justify tlie expense of a com- mission and the proceedings under it, the judge thereof, in person, shall hold said commission during the term of the court, and shall direct an inquest to be impaneled from the jurors attending said court, and which proceeding shall have like force and effect as an inquisition held by commissioners as aforesaid. Sec. 1354. — Jailer to Give Notice. If any person arrested or imprisoned as aforesaid, in any civil action, shall appear to be of unsound mind, it shiiU be the duty of the jailer or keeper of the prison forth- with to give notice of tlie fact to two justices of the peace, who shall within live days attend at the prison, and, upon the oath or affirmation of such persons as tliey shall think fit to examine, proceed to inquire into the state of mind of sucli prisoner, and if they shall iind him to be a lunatic as was alleged, they shall forthwith make a record of the fact and certify the same to the clerk of the District Court. Revised Statutes of New York, 1889. Chapter 446, Article 1, Section 1.— Commitment of the Insane. No person shall be committed to or confined as a patient in any insane asylum, public or private, or any institution, home, or retreat for tlie care and treatment of insane, except upon the certificate of two physicians, uiuler oath, setting forth the insanity of such person. No person shall be held in confinement in any such asylum for more than five days, unless within that time such certificate be apjiroved by a judge or justice of a court of ret-ord of the county or district in which the alleged 662 ArFEXDix. lunatic resides ; and sueli judge or justice may institute inquiiy and make proofs as to the fact of alleged lunacy before approving or disappro%-ing such certificate ; and such judge or justice may in his discretion call a jury in each ease to determine the ques- tion of lunacy. Sec. 2. — It shall not be la^wful for any physician to certify to the insanity of any person for the purpose of securing their commitment, unless the physician be of reputable character and a gi'aduate of some incorporated medical college, a permanent resident of the State, and shall have been in actual practice of his profession for at least three years ; and such qualifications shall be certified to by a judge of any coui't of record. Xo certificate of insanity shall be made exce^it after the personal exam- ination of the party alleged to be insane, and according to the fonns prescribed by the State Commissioner of Liinacy, and every such certificate shaU bear a date not more than ten days prior to such commitment. Sec. 3. — It shall not be la^^vful for any physician to certify to the insanity of any person for the purpose of committing him to an asyliun of which the said physician is either supeiintendent, proprietor, or officer, or a regular professional attendant therein. Sec. 4. — Every superintendent of the State asylum, or public or private asylum, institution, home, or retreat for the care and treatment of insane, shall, within thi-ee days after the reception of any patient, make, or cause to be made, a description of such case, entered in a book exclusively set apart for that pm-pose, and shall also make entries from time to titae mentioning state, bodily condition, and medical treatment of such patient, together with the forms of restraint employed during the time such patient remains under his care ; and in the event of discharge or death of such patient the superintendent aforesaid shall state in his ease-book the circum- stances pertaining thereto. Sec. 10. — Any overseer of the poor, constable, keeper of jail, or other persons who shall confine any lunatic in any seminary, or any other places than such as are herein certified, shall be deemed guilty of a misdemeanor, and on conviction thereof shall be liable to a fine not exceeding two hundred and fifty dollars, or imprisonment not ex- ceeding one year, or both, at the discretion of the court before which the conviction shall be had. Sec. 33. — When any person confined under the indictments of arson, mui-der or attempt to murder, or highway robbery, or who has been acquitted thereof on the grotxnd of insanity, and has been committed to some State lunatic hospital, . • . shall be restored to his right mind, it shall be the duty of the supei-intendent of such asylum to give notice thereof to the State Commissioner of Lunacy, who shall thereupon in- quire into the truth of the fact, and if the same shall be proved to his satisfaction he shall issue certificate, dated under his official hand and seal, to a justice of the Su- preme Coiu't of the district in which such asylum is situated, who shall thereupon and upon such other facts as may be proven before him determine whether it is safe, legal, and right that such party in confinement, as aforesaid, shall be discharged. Sec. 24. — Discharge of Patients. The managers, upon the superintendent's certificate of complete recovery, may discharge any patient, except when under a criminal charge or liable to be remanded to prison, and they may discharge any patient admitted as " dangerous," or any patient sent to the asyhmi by the superintendent or Overseers of the Poor, or by the (first) judge of the county, upon the certificate of the superintendent that he or she is harm- less, and will probably continue so, and not likely to be improved by fiu-ther treat- ment in the asylum, or when the asylum is full, upon a like certificate that he or she is manifestly inem-able and can probably be rendered comfortable at the poorhouse, so that the preference may be given, in the admission of patients, to recent cases, or cases of insanity of not over one year's duration. They may discharge and deliver the patient, except when under criminal charge, as aforesaid, to his relatives or fi'iends wlio will undertake, with good and approved sureties, for his peaceable be- ha^^or, safe custody, and comfortable maintenance without further public charge. And such sureties shall be approved by the county judge of the county fi-om which said patient was sent. . . . Upon the i)resentation of a certified copy thereof the man- agers may discharge such patient. APPENDIX. GG3 Code op North Carolina, 1883. Sec. 2249. — Superintendent — QHalifications. . . . He shall be a skillful physician, educated to his profession, of good moral ■character, of prompt business habits, and of kindly disposition. He shall hold his office for six years from and after his appointment, unless sooner ren]o\-ed . . . for inlidelity to his trust, gross immorality, or incompetency to discharge tlie duties of his office, fulfilled and declared, and the proof thereof recorded in the books. . . . Sec. 2250. — Assistant Physician. Each Board of Directors shall appoint one or more assistant physicians, and, with the advice and consent of the superintendent, prescribe his duties. Every assistant physician appointed shall hold his place for two years from and after the appointment, unless sooner removed by said board for good cause, which shall be specified and recorded in their proceedings. Sec. 2253. — Superintendent to Control Officers. Such superintendent shall exercise exclusive direction and control over all subor- dinate officers and employees engaged in the service and labors of his asylum, and he may discharge such as have been employed by himself or his ijredecessor, and shall report to the Board of Directors of the asylum the misconduct of all other suiaordinates. Sec. 2256. — Proceedings to Obtain Admission to the Asylum. For admission into the asylum for the insane the following proceedings shall be had : Some respectable citizen residing in the county of the alleged insane person shall make before, and file witli, the justice of the peace of the county, an affida'snt. . . . Upon the bringing of the alleged insane person before the justice of the peace, or upon the return of the precept with the body of the insane person, the justice shall cause to be associated with him one or more justices of the said county, who together shall proceed to examine into the condition of the mind of the alleged insane person, and shall take the testimony of at least one respectable physician, and such others as they may think proper. If any two of the justices of the peace shall be satisfied that the person is insane, and some friend, as he may do, will not become bound with good security to restrain him from committing injuries, support and take care of him until the cause for confinement shall cease, such justices shall direct such insane person to be removed to the proper asylum as a patient, and to that end they shall direct a war- rant to the shei'iff or constable, and at the same time shall transmit to the proper Board of Directors, on examination of the witnesses, a statement of the facts as the .said justices shall deem pertinent to the subject-matter. . . . Sec. 2259. — Action of the Superintendent in Boidttful Cases. "Whenever an insane person shall be conveyed to any as.ylum, and the superin- tendent is in doubt as to the propriety of his admission, he may convene any three of the Board of Directors of his asylum, who shall constitute a board for the purpose of examining and deciding that such person is a proper subject for admission, and if a majority of such board shall decide so, such person shall be received into that asylum ; but that a like board may at any time hereafter deliver such insane person to any friend who may become bound with good seciu'ity to maintain and take care of him in tlie same manner as he might have become bound under the surety of tlu^ justice of the peace. Sec. 22G0. — Discharge of the Cured — Eenioval of the Incurables. Any three of the Boai'd of Directors of any asyhim, upon the certificate of the superintendent, . . . shall be a board to discharge or remove from their asylum any person admitted as insane when such person has become or is fomid to be of sane mind, or when such person is incurable and in the opinion of the superintendent his being at large will not be injurious to himself or dangerous to the community; or said board may permit such person to go to tlie county of his settlement on pi'obation, when in tlie opinion of tlie said superintendent it will not be injurious to liimself or •dangerous to tlie community ; and said board may discharge or remove sueli person 664 AFPENDIX. upon other sufficient cause appearing to them ; and whenever any such person ad- mitted as indigent may be so discliarged or removed, except as sane, it shall be the duty of the sheriff of the county of his settlement to convey such person to his county at its expense ; and any indigent person discharged as sane shall receive from such asylum a sum of money sufficient to pay his transportation to the county of his settle- ment, which sum shall be repaid by said county. Acts of Ohio, Sec. 1. — Application for Admission to tlie Asylum. Be it enacted by the General Assembly of the State of Ohio that section 705 of the Revised Statutes of Ohio be amended so as to read as follows : Probate judge ujjon receiving certificate of medical witnesses . . . shall forthwith apply to the superintendent of the hospital for the insane situated in the district in which the patient resides ; he shall at the same time transmit copies under his official seal of the certificate of the medical witnesses and of his findings in the case. Upon receiving application for certificate, the superintendent shall immediately advise the probate judge whether the patient can be received, and, if so, at what time ; the pro- bate judge, when ad^dsed that the patient will be received, shall forthwith issue his warrant to the sheriff, commanding him forthwith to take charge of and convey such insane person to the asylum. . . . Sec. 709. — Discharge of Patients from the Insane Asylum. ... On consent and ad^^ce of the trustees the superintendent may discharge any patient from any asylum for the insane, when he deems such discharge proper and necessary ; provided, no patient with known homicidal or suicidal propensities shall be discharged without a bond in the sum of one thousand dollars, with two or more sm-eties, to be approved by the probate judge of the county of which the patient is an inhabitant, payable to any person who shall be injured in person or property by any insane act of such discharged person while at large. Any incurable or harmless patients may be discharged to make room for acute cases from the same cormty ; and no patient vdih known homicidal or suicidal pro- pensities shall be hereafter kept in any county infirmary or jail of the State, except temporarily, while awaiting the order for removal to the State Asylum for the Insane. "When in the opinion of the superintendent the condition of the patient at the time of discharge is such as to justify sucli action he may permit such patient to go to his home or leave the institution unattended ; and if such patient is not financially able to bear his own expenses the superintendent of the institution may fui'nish the patient a sufficient sum to pay his traveling expenses, and charge the same to the current ex- pense fund of the institution ; such sum shall in no one case exceed twenty dollars. . . . Sec. 704. — Certificates of Medical Attendants. At the time (unless for good cause the investigation is adjourned) the judge shall proceed to examine the witnesses in attendance ; and if upon reading the testimony he is satisfied that the person so charged is insane, he shall cause a certificate to be made out by the medical witnesses in attendance. . . . Sec. 710. — When Discharged as Cured. When a patient is discharged as cured the superintendent may furnish such patient with suitable clothing and a sum of money as he deems fit, not in any case exceeding twenty dollars. Sec. 712. — Proceedings when Person Becomes Again Insane. When a patient discharged from an asylimi for the insane as cured again becomes insane, and a respectable physician files with the judge of probate of the county of which the insane person is an inhabitant an affidavit setting forth the fact of the recurrence of the disease, and such other facts relating tliereto as he deems proper, the probate judge shall forthwith transmit a copy of such affidavit, authenticated by his official seal, to the superintendent of the proper asylum^ and thereupon the same APPENDIX. GG5 proceeding shall bo had as provided in this chapter for persons found to he insane upon inquest for that purpose. Sec. 715. — When Patient iJieii, Ilclaiivcs nUull he Notified. When a patient dies in any one of the asylums for the insane, the superintendent thereof shall immediately notify relatives of such deceased patient, if known to him ; and, if not so known, he shall immediately notily the probate jud<Sec. 1^4. — ll'licii Dclcitlioii Unnecessary, Notice to be Given. In case the said incdiciil attendant is of the opinion that detention is not necessary for the benefit of tlie patient, he shall notify tlie person or persons at whose instance the patient is detained, and unless sucli a jjerson shall witliout a delay not exceeding seven days ex]nl)it satisfactory proof of such necessity, the patient shall be discharged from the house and restored to his family or friends. Sec. 25. — Intervicivs AUnivcd. At the time of such examination the medical attendant shall himself cause tlie patient strictly to rmderstand, if he or she is capable of doing so, that if he or she desires to see or otherwise connuunicate with any person or persons, means will be provided for such interview or communication, and said attendant shall see that the proper means are taken to communicate this fact to the person or persons indicated by the patient ; or any proper person or persons not exceeding two shall be permitted to have a full unrestrained interview with the patient. Sec. 26. — Reports to he Made hij the Medical Attendant. The statement furnished at the time of the reception of the patient (and of the examination of the patient by the medical attendant of the house) shall be forwarded by mail to the address of the Committee on Lunacy within seven days from the time of the reception of the patient, which shall by them be entered in a book which shall be kept for the purpose, and at least once in six months there shall be reports made by the medical attendant of the house on the condition of the patient, together with such other matters relative to the case as the said committee may require ; and at the same time such report shall be made by request of the secretary of the Committee on Lunacy. Sec. 28. — Materials for Correspondence, etc. All persons detained as insane shall be furnished with materials and reasonable opportunity, under the discretion of the superintendent or manager, for communicat- ing, under seal, without the building, and such comnmnieation shall be stamped and mailed. They shall have the unrestrained privilege of addressing communications, if they so desire, not oftener than once a month, to any member of tlie Committee on Lunacy. Sec. 31. — Persons Restored to Reason to he FortJucith Discharged. All persons that have been detained as insane (other than criminal insane duly convicted and sentenced by a court) shall, as soon as they are restored to reason and are competent to act for themselves, in the opinion of the medical attendant of the house, be forthwith discharged ; and any person so detained shall at all times be en- titled to a writ of habeas corpus for the determination of this question. ... In case the discharged patient be in indigent circumstances, such person shall be furnished with necessary raiment and with funds sufficient for sustenance and travel to his home, to be charged to the county from which such patient was committed. Sec. 32. — Committee to he Notified of Discharges. The Committee on Lunacy shall be notified of all discharges within seven days thereafter, and a record of same shall be kept by the committee. Sec. :}6.— Postal Privileges of the Patients. ..." That it shall be unlawful and be deemed a misdemeanor in law, punishable by fine not exceeding one hundred dollars, for any superintendent, officer, physician, or other employee of any insane asylum, to intercept, delay, or interfere mth, in any manner whatsoever, the transmission of any letter or other written communication addressed by an inmate of anj' insane asylum to his or her counsel residing in the county in wliich the home of the patient is, or the State or county in which the asylum is located," is hereby amended so that the same shall extend to superintendents, 6G8 APFENDIX. offieei's, servants, or other employees of all hospitals, houses, or places which are sub- ject to the provision of this act. Statutes of Rhode Island, May, 1884 — January, 1885. Chapter 479. — Apportionment of Insane Paupers at the Butler Hospital or other Curative Hospitals. Whenever it shall appear by the written certificate of two practicing physicians of good standing that any pauper within the State is insane, and may be benefited by curative treatment, the agent of State Charities and Corporations, with the "written consent of the govei'nor, may place such insane pauper in the Butler Hospital for the Insane ; but in case such pauper cannot be received in the said hospital, then at some public curative hospital for the insane within the State. Public Statutes of Rhode Island, 1882. Chapter 74, Section 1. — Whenever complaint in writing and under oath shall be made to any trial justice or clerk of a justice court, that any person within the county is a lunatic, or so furiously mad as to render it dangerous to the place or safety of the good people of the State for him to be at large, and that such person is at large, such trial justice or clerk shall issue his warrant, under his hand and seal and returnable forthwith, directed to the dejjuty sheriffs, town sergeants, or constables, requiring the officer charged therewith to apprehend such person, and convey him with such warrant before such or some other Justice Court for examination relative to such com- plaint. Sec. 2. — Examination and Proceedings onMeturn of tlie Warrant and Commitment of the Mad Person. If the court on such examination shall adjudge such comj)laint to be true, it shall, unless a recognizance satisfactory to said coiirt be then given before it that said per- son shall not be permitted to go at large until restored to soundness of mind, commit such person by warrant imder its hand and seal to the Butler Hospital for the Insane, or to the State Hospital for the Insane, there to be detained until, in the judgment of some justice of the court of the county in which he may be detained, he shall, upon inspection and examination, be declared to be restored to soundness of mind, or to be no longer under the necessity of restraint, or imtil recognizance as aforesaid, satis- factory to such court, shall be given. Sec. 10. — When a Person Committed may he Discharged though not Cnred. Any person committed to any such institution under the previous proceedings of tlie fourth section may, although not restored to sanity, be discharged therefrom upon the written recommendation of the trustees and superintendent thereof, or an order of any justice of the Supreme Court, to be made in his discretion. Sec. 11. — Commitment of Lunatics. Insane persons may be removed to and placed in the said Butler Hospital or State Asylum for the Insane, if they can be there received, and, if not, in any other cura- tive liospital for the insane of good repute in this State. . . . But the superintendent of said hospital shall not receive any person into his custody in such case without the certificate from two practicing physicians of good standing, known to him as such, that such person is insane. Sec. 12. — Powers of Superintendent to Pcceive ami Detain Lunatics. Any person committed to the charge of any of the said institutions for the insane as aforesaid, in either of the modes herein described, may lawfully be received and detained in said institution by the superintendent thereof, and by his keeper and servants, iintil discharged bj^ any one of the modes herein provided; and no super- intendent, his keepers or servants, nor the trustees or agents of same, shall be liable, ^civilly or criminally, for receiving or detaining such person so committed or detained. APPENDIX. GG9 Sec. 14. — Siq)eriutc)ulent may Discharge — JVlien. Tlie superintendent of such institution for the insane within the State may, on ilie application of any rehitive or friend, witli the proper approval in writing of the visiting committee or trustees, discharge from such institution any jjatient not com- mitted by process of law. Sec. 30. — To Visit Insane Persons. The State Commission, or either of the members thereof, shall from time to time in their discretion visit every institution or place wherein any person insane or alleged to be insane is restrained of his liberty, and alone or attended, as they shall elect, -examine into the condition and complaint of any one so confined. Sec. 31. — Duty of Persons in Charge of Insane Persons. The superintendents, officers, keepers, and assistants, and other persons in charge ■wherever any insane person is confined, are forbidden and enjoined fi-om in any way or manner interfering, hindering, or preventing anj' person so confined from com- municating at all times, in manner as aforesaid, witli said commission, except under consultation, and with the full consent in writing of the commission. And every such superintendent, officer, keeper, and assistant, or other person, shall afford to every person under his charge, with the exception of the aforementioned, every facility for making such communications, according to the true intent and meaning thereof, and ■shall forward such communication to the said commission without delay. Laws op South Carolina, 1884-. Act 508, Sfx'. 1. — Certifieate of Physicians. . . . Physicians examining summoned persons alleged to be insane for admission to a limatic asylum shall certify under oath that they are registered in accordance with tlie State law, that they have examined the persons separately, and that they are not related by blood or marriage to any of the persons ; they shall also certify under oath that to the best of tbeir medical knowledge the persons they recommend for admission to the lunatic asylum are epileptics, idiots, or lunatics, incurable at home, and that they are violent or dangerous. Sec. 2. — Idiots, Epileptics, etc., not to he Sent unless Violent. Physicians giving certificates recommending commitment to the asylum of a per- son who is simply idiotic, epileptic, physically infirm, or mentally imbecile, imless such person is violent or dangerous, shall be deemed guilty of a misdemeanor, and upon conviction thereof shall be fined by the District Coui't. Laws of 1882. Act 121, Sec. 1. — Terms and Conditions upon which Patients may he Admitted into the Asylum. . . . The superintendent and regents of the State Lunatic Asylum shall not re- ceive into said institution any beneficiary patient uidess the order consigning sucli person to the asylum is accompanied by report from the County Commissioners of the county from which such person is sent, certifying that they have carefully investi- gated the circumstances and condition of such person, his or her family, parent, or guardian, and that such person is a proper subject for the beneficiary care, and to what extent. South Carolina Laws, 1881-82. Chapter 64G, Sec. 1. — How Lunatics are to be Sent to the Asylum. . . . All officers now authorized by law to send insane persons to the lunatic asylum shall, before sending such insane person to the asylum, notify the chairman 670 APFEyDIX. of the Board of County Commissioners, or the clerk of sneh "board, that such person should be sent to the lunatic asylum, having first had such lunatic, if of a dangerous- or violent character, so secured as not to do any damage or injiuy. . . . Sec. 1586. — How to be Admitted to the Asyhoii. It shall be the duty of the regency to admit as subjects of the institution all idiots, lunatics, and epileptics, under the statutes of this State and subject to the foUowing^ conditions, that is to say : ... (3) all persons who shall be declared lunatics, idiots, or epileptics. After due examination by one trial justice and two licensed practicing^ physicians of the State where the subject is a pauper, the admission shall be at the request of the County Commissioners wherein such pauper has a legal settlement ; otherwise the admission shall be at the request of the husband or wife, or, where there is no husband or wife, of the next of kin of the idiot, lunatic, or epileptic. Sec. 1588. — Judges may Direct Inquisition. Whenever a judge of probate or a judge of the Cii'cuit Court shall direct an order to any trial justice to inquire as to the idiocy, lunacy, or epilepsy of any jaerson, or when information on oath shall be given to any trial justice that a person is an idiot, lunatic, or epileptic, and is chargeable for his support on the county, it shall be the duty of said trial justice forthwith to call to his assistance two licensed practicing^ physicians, and examine such person as to e^ndence of his or her idiocy, lunacy, or epilepsy ; and if after full examination they shall find such person an idiot, lunatic, or epileptic, they shall certify to said judge or Board of Comity Commissioners whether in their opinion such person is cui-able or incui-able, and whether his enlargement would be harmless or dangerous or annoying to the community; and thereupon the judge or Board of County Commissioners in its discretion may make an order that the said person shall be sent to the lunatic asylum. Sec. 1594. — Discharge of Lunatics. "Whenever any lunatic or epileptic shall have recovered, it shall be the dutj' of the regents to discharge him from the asjdum. Sec. 1596. — 111 Treatment of Patients h\j Employees. It shall be the duty of the regents to remove from office and cause to be indicted any person employed in said institutions who shall assault any idiot, lunatic, or epileptic with any other or greater violence than may be necessary for his or her restraint, government, or cm-e. Code of Tennessee, 1884. Article 2, Section 2027. — Qualifications of Snpei-intendent. The superintendent of the hospital shall ,be appointed by the Board of Trustees,, and shall be a skillful physician, of unblemished moral character, of enlightened and thorough professional education, of prompt business habits, and of humane and kind disposition. Sec. 202S.—Eesidcnce, etc. He shall be a married man, and with his family shall reside constantly in the institution. Sec. 2029.— Term of Office. He shall hold his office for eight years, but may be removed by the Board of Trus- tees for infidelity to his trust or incompetency fully shown and declared. Sec. 20.30.— Po«Tr.s- over Officers. He shall exercise entire control over all subordinate officers and assistants in the hospital, and shall have entire direction of the duties of same, he himself being' accountable to the Board of Trustees for their good character and fidelity in the dis- charge of their duties. AL't'ESDlX. 671 Sec. 2Q'iQ.— Duties. It shall Ije the duty of the superintendent, under the orders of the Board of Trus- tees : First, to exercise a f?eneral superintendeney over all matters relating to the hospital. Second, to visit the patients therein at least twice a week, or (jttener if necessary. Third, to call meetings of extraordinary importance of the Board when- ever he may deem it necessary. Fourth, to report to the trustees immediately before each general assembly, first, the number of patients admitted into the asylum ; sec- ond, date of admission of each patient ; third, the degree and kind of insanity with which each patient is afflicted ; fourth, length of time each person was supposed to have been affected before admission ; fifth, the profession, occupation, age, and habits of each patient, and whether married or single ; sixth, tlie names of those discharged, and the condition of each when discharged; seventh, and such other particulars as he may deem necessary to fiu-ther action and legislation thereon. Sec. 2037. — In Reference to Removal of Patients. The superintendent, by authority of the resident Board of Trustees or a majority of them, shall have power to require the removal of any patient, paying or non-pay- ing, whenever in their opinion it is advisable to do so. Title 7, Kevised Statutes of Texas, 1879. Article 67. — Board of Managers. The general control and management and direction of the affairs of the State asylums shall be vested in the Board of Managers, to be styled the "Board of Man- agers of the Lunatic Asylums." Art. 73. — Monthhj Insjycction. One or more of the managers shall visit the asylum and inspect the same at least once every month. Art. 75. — Superintendent Provided for. The governor of this State shall appoint, by and with the ad^dce and consent of the Senate, a superintendent of the lunatic asylum, who shall, unless sooner removed, hold his office for a term of two years ; and in the case of a vacancy in said office the appointment shall be only for the expiring term, and the term of such officer shall, in any event, expire with the term of the governor making the appointment. Art. 76. — Qualifications of the Superintendent. The superintendent shall be a married man, and also of experience in the treat- ment of insanity. He shall reside in the hospital with his family, and shall devote his whole time exclusively to the duties of his office. Art. 80. — Powers and Duties of the Superintendent. The superintendent shall be the chief executive, medical, and disbiu'sing officer of the institution, and subject to the by-laws, but shall have general care and control over everything connected therewith. He shall attend to the enforcement of the laws of the State relating to the asylum, and by-laws of the institution, and shall take care that all employees connected therewith diligently and faithfully perform duties as- signed to them. Art. 81. — The superintendent shall also, with the consent of the Board of Mana- gers, CTuploy such officers, attendants, and other persons as may be required for the service of the institution, and with like consent may discharge them at pleasure. He shall also receive and discharge patients, superintend repairs and improvements, and take care that all moneys intrusted to him are judiciously and economically ex- jiended. Art. 82. — The superintendent shall keep also an accurate and detailed account of all moneys received and expended by him, certifying the source from which such moneys were received, and to which and on what account to be xised ; and on the first day of July of each year he shall report the same under oath to the governor. ^72 APFEXDIX. Art. 83. — The supermtendent shall also keep and register patients received into the asylum and discharged therefi'om, together with a full record of all the operations of the' institution, and on the first day of November of each year he shall report such operations in full to the governor, accompanied with such suggestions and recom- mendations concerning the management and operations of the asylum as may be deemed important. Art. 84. — Annual Inventory . On the first day of November of each year the superintendent shall cause inventory of all the personal property belonging to the asylum to be prepared, in AvMch inven- tory an estimated value shall be set beside each article, and shall submit the same to the Board of Managei's. Art. 92. — Before any person can be received as a patient . . . the parent or legal guardian of such person, or, in case he has no parent or guardian, then some near relative or other person interested in him, must present a wi-itten request to the super- intendent for his admission, setting forth the name, age, residence of the Itmatie, together with such particulars as may be required by the superintendent or the by-laws of°the institution ; which written request must be under oath of the party presenting it, and be accompanied with an affidavit of the physician certifying to the insanity, that he has made a careful examination of the person for whom admission is applied for, and verily believes him to be insane. Art. 93. — County Judge must Certify. The application referred to in the preceding article must also be accompanied by the certificate of the county judge of the county where the lunatic resides, that the phvsician certifying to the insanity of the person under charge is a respectable physi- cian in regular practice ; which certificate of the county judge must be attested by the seal of the County Court of his eoimty. Art. 99. — Discharge of Patients. Any patient, except such as are charged with or con-^-icted of some offense and liave been adjudged insane in accordance -R-ith the pro^-isions of the Code of Criminal Procedure, may be discharged from the asylum at any time upon the recommendation of the superintendent, approved by the Board of Managers. Any patient coming within the above exception can only be discharged by order of the court by which he was committed. Art. 100. — Xo patient shall be discharged without suitable clothing and sufficient money to pay his expenses home ; and when a patient is discharged by order of the court he shall be provided with a suitable guard and conveyed to his fi'iends, or to the county from which he was sent. Art. 106. — Apjirehension of Lunatics. If information written under oath be given to any county judge that any person ui his coxinty is a lunatic or non compos mentis, and that the welfare of himself or of others requii'es "that he be placed under restraint, and said county judge shall believe such information to be true, he shall forthwith issue his warrant for the apprehension of such person, and shall fix a day for the hearing and detennination of the matter. Art. 120. — Suitable Clothing to he Provided. Before sending any patient to the asylum the coimty judge shall take care that the patient is provided with two full suits of substantial summer clothing and one full suit of substantial winter clothing. Laws of Utah, 1880. Chapter 31, Section 13. — Qualifications of the Medical Superintendent and his Duties. The medical superintendent shall be well educated, an experienced physician, and a regular graduate in medicine, and .shall have practiced at least five years fi'om the ■date of his diploma. He shall have the general superintendence of the buildings. APPENDIX. 673 grounds, iiiul property tliorcof, suhjpct to the laws and regulations of the directors. He sliall luive t-oiitrol of the patients, ^jreseribe tlieir treatment, adopt sanitary meas- ures for their welfare, and diseluirge sueli as in his ojjinion have permanently recovered their reason. He shall appoint, with the approval of the directors, as many attendants as may be necessary for tiie efficient and economic care and management of the asylum, and, with the consent of tlie Board of Directors, fix their compensation and discharge any of them. He shall prescrilie tlie duties of the subordinate officers, maintain dis- cipline among them, and enforce obedience to the laws, rules, and regulations adopted for tlie government of the institution. He shall estimate quarterly, in advance, the proV)able expenses of the asylum, and submit the same to the Board of Directors at their regular meeting preceding the commencement of sucli quarter, for their approval. . . . TJie medical sui)erintendent sliall cause to be kept full and accurate accounts and records of his official transactions from day to day, in books provided for that purpose, in the mode prescril)ed in the by-laws. He shall see that his accounts are fully made xip to the olst of December in each year, and shall submit his annual report to the Board of Directors immediately. He shall visit the asylum every day in the year, un- less he obtain leave of absence from the president of the Board of Directors, in which event the assistant physician shall discharge his duties. . . . Sec. 16. — Judge of Frohate may, if Found Necessary, Direct that Insane Persons he Placed in an Insane Asylum. The probate judge of any county in this Territory shall, upon application under oath, setting forth that a person, by reason of insanity, is dangerous to be at large, caiise such person to be brought before him, and he shall summon to appear, at the same time and place, two or more witnesses who well knew the accused during the time of alleged insanity, who sliall testify, under oath, as to the conversation, manners, and general talk upon which charge of insanity is based ; and shall also cause to appear be- fore him, at the same time and place, two practicing physicians in medicine, before whom the judge shall examine the charged ; and if, after a careful hearing of the ease and a personal examination of the alleged insane person, the said physicians shall cer- tify, on oath, that the person is insane, and the case is of recent or cui'able character, or that the insane person is of homicidal, suicidal, or incendiary disposition, and that from any other violent symptoms the said insane person would be dangerous to his or her own life, or to the lives or property of the community in which he or she may live, and the said physicians shall also certify to the name, age, nativit}^ residence, occupa- tion, length of time in the Territory, State, or county last from, previous habits, pre- monitory symptoms, apparent cause, and class of insanity, duration of the disease, and present condition, as nearly as may be ascertained by inquiry and examination ; and if the judge shall be satisfied that the facts revealed in the examination establish the insanity of the person accused, and that it is of a recent or curable nature, or of homi- cidal, suicidal, or incendiary character, or that from the violence of the spuptoms the said insane j)erson would be dangerous to his or her own life, or to the lives or property of others, if at large, he shall direct a sheriff of the county, or some suitable person, to convey to and place in charge of the officers of the Territorial Insane Asylum such person, and shall transmit a copy of the complaint and commitment, and physicians' certificate, which shall also be in the form furnished by the medical superintendent of said asylum. ... Vekmont, 1884. Act No. 52, Section 1. — It is hereby enacted by the general assembly of the State of Vermont, that section 2898 of the Eevised Laws is hereby amended so that it will read as follows : The supervisors shall visit the Vermont Hospital for the Insane as often as occasion requires, and one member as often as once a month, and also any other place where insane persons are confined in the State, at their discretion ; shall examine into the condition of the said asylum, and such other places where insane persons are confined, the management and treatment of the patients therein, their physical and mental con- dition, and medical treatment ; form a careful opinion of the patients, apart from the officers and keepers, and investigate the cases that in their judgment require special investigation, and jiarticularly ascertain whether persons are confined in sxich nsylnra oi' (itlier places who ought to be discharged. They shall liave the general supervision of the insane of the State not in confinement, so far as it concerns their physical and 674 AFFEXLIX. mental condition, their eare, management, and medical treatment ; and also those "who are discharged from such asvlum or place of confinement bv authority under section 4 of the act approved November 28, 1882, and shall make such order therein as such ease requires. Eevised Statutes, 1880. Chapter 139, Section' 2897. — Siq)ervisors. The general assembly shall elect biennially three Supervisors of Insane, who shall hold their office for two years, commencing on the first day of the next December ; and the governor may fill vacancies of the board during the term. Two of said supervisors shall be physicians, and none of them shall be a tmstee, superintendent, employee, or other officer of an insane asylum in the State. Sec. 2900. — Powers of tlte SupervisQrs. The supervisors may administer oaths, summon witnesses before them in any case Tinder investigation, and discharge by their orders in wi-itiug any person confined as a patient in any asylum for the insane whom they find on investigation to be wrong- fully confined, or whom they find so far sane as to wan-ant discharge. But convicts sent to an asylum from the State Prison or House of Correction who are found sane before the expiration of their sentence shall not be discharged, but the super^-isors shall order their return to the Prison or House of Correction. In no case shall the siiper- visors order the discharge of a patient without giving the superintendent of the asylum an opportunity to be heard. Sec. 2905. — Fine for not FJiseharging Patient after Fecovery. If a trustee, superintendent, employee, or other officer of any asylum for the insane woUfully and knowingly neglects or refuses to discharge a patient after such patient has become sane, or after the suiDcrvisors have ordered his discharge, such trustee, sujterintendent, employee, or other officer shall be fined not more than five hundred dollars. Sec. 2906. — Physicians' Certificate Fequired. Xo person, except as hereinafter provided, shall be admitted or detained in an in- sane asylum as a patient or inmate except upon the cei'tificate of such person's insanity, made by two physicians of unquestioned integi'ity and skill, residing in the probate district in which such insane person resides, or, if such insane person is not a resident of the State, in the probate district in which the asylum is situated ; or if such insane person is a conA-ict in the State Prison or House of CoiTection, such physicians may be residents of the probate district in which such place of confinement is situated. Sec. 2907.— Certificate— TJlien to he Made. Such certificate shall be made not more than ten days pre'S'ious to the admission of such insane person, and, with the cei'tificate of the judge of probate of the district in which the physicians reside that such physicians are of unquestioned integi'ity and skill in their profession, shall be presented to the proper officer at the time such insane per- son is presented for admission. Sec. 2908. — Physicians to Certify upon E.camination. The certificate of the physicians shall be given only after a careful examination of the supxjosed insane person, made not more than five days preAious to the gi^-iug of the certificate ; and the physician who signs the certificate without making such pre^-ious examination shall, if the person is admitted to any asylum under the certificate, be fined not less than fif tv dollars and not more than one hundred dollars. Code of Virginia, 1887. Sec. IQQS.— Annual Beports. The board of each asylum shall annually before the first day of November report to the governor, for the information of the general assembly, tlie condition of the asylum. ArrEM)ix. G75 and an aeeonnt of all sums refeived anil disbursed, with a list of the patients desig- nated by name or otherwise in the asylum during the preceding year, showing their age and sex, place of residence, and civil condition, deaths, and discharges, and con- dition when discliarged, and any statistics and remarks as to the management of insane and the subject of insanity wliich in their judgment nuiy be useful. Sec. 1669. — Any justice who suspects any person in his county or corporation to be a limatie shall issue his warrant ordering such person to be brought before hira. He and two otiier justices shall ini|uire whether such i>erson be a lunatic, and for that purpose summon his pliysician (if any) and any other witnesses. . . . Sec. 167(1. — If tlie justices decide that the person is a lumitic and ought to be eon- fined in an asylum — unless some person (to whom the justices, in their discretion, may deliver such lunatic) will give bond, witli sufficient security, to be aj>proved by them, payable to the commonwealth, with condition to restrain and take proper care of such lunatic until the cause of his confinement shall cease, or the lunatic is delivered to the sheriff of the county or corporation, to be proceeded with according to law — the said justices shall order him to be removed to the nearest asylum on receipt of notice of there being room therein, and, if not, to either of the others. Sec. 1673. — The superintendent of the asylum, when such vacancy exists, is author- ized, when practicable, to send a guard for the lunatic, or emjiower any person of responsibility and character to guard and conduct him to the asylum, and furnish the person so appointed with a certificate of his appointment ; or, when neither of such ai'rangements are practicable, the sheriff shall conduct such lunatic to the asylum. . . . Sec. 1674. — Examination and Admission of Lunatics. When such patient arrives at the asylum the superintendent or his attendants shall examine him, and if they concur in opinion with the justices shall receive and register him as a patient. Sec. 1688. — Discliarge of other Restored Lunatics. When any other person confined in an asylum or jail as a lunatic shall be restored to sanity, the superintendent or the cornet, as the case may be, shall discharge him and give him a certificate thereof. Code of Washington, 1881. Sec. 2251. — Appointmoit and Qualifications of Superintendent. The superintendent shall be a skillful practicing physician, and shall reside upon the hospital grounds ; he shall hold his office for such time as the trustees may deem wise and for the efficiency and economy of the institTition ; he shall have entire control of the medical, moral, and dietetic treatment of the patients, and, so far as is not in- consistent with the by-laws and regulations of the hospital, of all other internal govern- ment and economy of the institution ; and he shall, in such manner and under such restrictions and for such terms of time as the by-laws may prescrilie, appoint all sub- ordinate employees, and shall have entire direction of them in their duties. Sec. 2260. — No Person Laboring under Contagious Disease Admitted. No person laboring under any contagious or infectious disease shall be admitted in said hosijital as a patient. Sec. 2264. — When and How Patients may he Discharged. Any patient may be discharged from the hospital when in the judgment of the superintendent it may be expedient. Whenever a patient not cured or any indigent patient shall be ordered discharged, the superintendent shall immediately give notice thereof to the probate judge of the county in which said patient resided ; and if in the judgment of the superintendent such patient so ordered to be discharged is in fit con- dition to be sent to his or her coimty unattended by any jjerson, the superintendent may return the patient to the county from whence he or she came, if indigent, at the expense of said county ; but if such patient so ordered to be discharged from said hos- pital and care, without endangering tlie health of such patient, is througli or by any reason unfit to be sent alone to the county from which he or she was committed to said hospital, the superintendent shall so certify to the probate judge of said county, who 676 APPENDIX. shall immediately upon receipt of the notice issue Ms waiTant to the sheriff, command- ing him to remove the patient and retiu'n him or her to the county from whence he or she came. If within thirty days after the notice the patient be not removed, the superin- tendent, if he think necessary, may return the patient to the county from which he or she came at the expense of the county ; provided, that if any such patient is not in a condition to either go or be removed to said county he or she may, for the time being, be retained in said hospital at the expense of the county from which he or she was so committed. Sec. 2267. — TJie Super intendent shall Ascertain History of eacli Patient. It shall be the duty of the superintendent to ascertain, by diligent inquiry and correspondence, the history of each and every patient admitted to the hospital, and whether such patients, or their friends or families, if there be any, are able to defray the expenses of his or her care, and report the facts to the Board of Trustees, who shall use efficient means for the collection of all sums due the institution from those who are able to pay for such care. Sec. 2273. — Corresjyondence of Patients Free from Censorsldp. There shall be no censorship exercised over the correspondence of inmates of insane asylums, except as to the letters to them directed ; but their other post-office rights shall be as free and unrestrained as are those of any other resident or citizen of this^ Territory, and be under the protection of the same postal laws ; and every inmate shall be allowed to write one letter per week to any person he or she may choose. And it is hereby made the duty of the superintendent to furnish each and every inmate of each and every insane asylum, both pjublic and private, in the Territory of Washing- ton, with suitable material for writing, inclosing, sealing, stamping, and mailing letters sufficient for wi'itiug of one f oui'-paged letter a week, provided they request the same, unless they are otherwise furnished with it; and all these letters shall be dropped by the Tvriters themselves, accompanied by an attendant when necessary, into a post- office box, provided by the Territory at the institution, in some place easily accessible to all the patients ; and the contents of these boxes shall be collected at least as often as once a week by an authorized post-office agent. And it is hereby made the duty of the supeiintendent of every insane asylum in the Ten-itory of Washington, both public and private, to deliver or cause to be delivered to said person any letter or wi-iting to- him or her directed, provided the physician in charge does not consider the contents of such letter dangerous to the mental condition of the patient. Sec. 2282. — Upon Delivery of Patient, Superintendent must Give Certificate, Stating Name of Patient and County. Whenever any patient is delivered at the asylum under the i)rovisions of this act, the superintendent of the asylum shall give to the sheriff or guard delivering such patient, a certificate stating the name of the patient, from what county admitted, and the court that committed the same. Laws of Washington, 1883. Sec. 1632. — The Probate Court of any county in this Territory, or the judge thereof, upon application of any jjerson under oath, setting forth that any person by reason of insanity is unsafe to be at large or is suffering under mental derangement, shall cause such jjerson to be brought before said court or judge, at such time and place as the court or judge may direct, and shall cause to appear at said time and place one or more respectable physicians, who shall imder oath, in writing, give their opinion of the case, which opinions shall be carefully preserved and filed with other papers in the case ; and if the said physician or physicians shall certify to the insanity or idiocy of said person, and it appear to the satisfaction of the coiirt or jridge that such is the fact, said court or judge shall cause such insane or idiotic person to be taken to and placed in the Hospital for the Insane of Washington Territory ; provided that such person, or any person in his behalf, may demand a jury to decide upon the question of his insanity, and the court or judge shall discharge such person if the verdict of the jury is that he is not insane ; provided, also, that when the relations or friends desire to take charge of such insane or idiotic person the court or judge may so order, if they shall give bonds, to be approved by said judge, conditioned that such insane or idiotic person shall be well and securely kept. A I' r LSD IX. C77 Amended Code of West Virginia, 1884. Chapter 58, Section 7. — West Virpoiiitcd Ity the board, and shall receive such coniiiensation as tlie board may prescribe. The T)oard may also ai»point an executive committee, and may authorize the su])erintendent to eiuj)loy as jnany nurses and attendants as may be necessary, ami also discharge them, or any of them, and em- ])loy otliers, ))ut the board shall fix their compensation. Any one or more of the directors, together with the superintendent, shall constitute an Examining Board, and may examine i)ersons brought to thc^ asylum as lunatics, and order those found to be such to be received. Sec. 11 (Acts of 1882, p. 1.33).— Any justice who sluiU suspect any person in his county to be a lunatic shall issue his warrant, ordering such person to be brought before him. He shall inquire whether sucli person be a lunatic, and for that purpose summon a physician aiul other witnesses. In additioji to any other questions he may propound as many of the following as may be applicable to the case : 1. AVhat is the patient's age, and where born? 2. Is he married; if so, how many children has he? 3. "Wliat are his liabits and occupation? 4. How long since indications of insanity ap- peared? 5. What were they? 6. Does the disease appear to increase? 7. Are there l)eriodical exacerbations ; any lucid intervals, and of what duration? 8. Is his derange- ment evinced on one or on several subjects ; what are they? 9. What is the supposed cause of his disease ? 10. What change is there in his bodily condition since the attack? 11. Has Ihei'e been a former attack; when, and of what duration? 12. Has he sIio^ati any disi)osition to commit violence to himself or others? 13. Whether any, and what restraint has been imposed on him? 14. If any, what connections of his have been insane. Were his parents or grandparents blood relations ; if so, in what degree? 15. Has he any bodily disease from suppression of evacuations, emiptions, sores, injuries, or the like, and wliat is its history? What ciu-ative means have been pursued and their effect, and especially if depleting remedies, and to what extent, have been used ? Sec. 12. — If the said justice decide that the person is a lunatic and ought to be confined in the hospital, and ascertain that he is a citizen of this State, then — unless some person to whom the justice, in his discretion, may deliver such hmatic, will give boiul, with sufficient security, to be approved by said justice, payable to the State, with condition to restrain and take piroper care of such lunatic until the cause of confinement shall cease, or the lunatic is delivered to the Sheriff of the county, to be proceeded with accoi'ding to law — the said justice shall order him to be removed to the hospital and received, if there be room therein. Sec. 23. — JJlioi PcrsoHs dkuj he Discharged from HospiiaJ. Except in the case of a person charged with crime and subject to be tried therefor, or convicted of crime and subject to be punished therefor, when in a condition to be so tried or punished, the board of the hospital, or the circuit coiu't of any coimty. may deliver any lunatic confined in the hospital or in the jail of such county to any friend who will give bond with security, Avith the condition mentioned in the twelfth section of this chapter ; and where a lunatic, except as aforesaid, is deemed by the superintend- ent of the hospital both harmless and incurable, the board may deliver him without such bond to any friend who is Avilling and, in the opinion of the board, able to take care of liim. Sec. 50. — (Iciicral Prorisiinis. If any director of the hosi)ital. justice, clerk of a court, or other officers shall fail to perform any duty required of him in the chajiter, or shall offend against any prohibi- tion contained herein, he shall forfeit not less than fifty nor more than one hundred dollars. Sec. 51 . — The word " lunatic, " whenever it occurs in this chapter, shall be consti'ued to include every insane person who is not an idiot. 678 APPENDIX. Revised Statutes of Wisconsin, 1879-1883, Chapter 32, Section 588. — Duties of the Superintendent. The siiperinteudent of each hospital shall, before entering upon the duties of his office, take and subscribe an oath faithfully and diligently to discharge the duties re- quired of liini by law and the by-laws of the Board of Trustees. He shall be chief executive officer of the hospital, and shall devote all his time and. attention to his duties ; he shall exercise entire control over all the subordinate officers ; he shall employ all employees and assistants necessarily connected with the institution below the grade designated in the by-laws as officers, and may discharge any officer, assistant, or em- ployee at will, being responsible to the Board of Trustees for the proper exercise of that dutj^ in regard to officers. The sujjerintendent shall not be compelled to obey the subpoena of any coiu't in any case, civil or criminal, if he shall tile with the magistrate or clerk his affidavit that to obey the same would be seriously deti'imental and hazard- ous to the welfare of the hospital under his charge, except when an accusation of murder is to be tried ; nor in such case, unless the judge shall make a special order therefor, and the subpoena, with a memorandum thereof indorsed thereon, be served one week before the time when he shall be required to appear ; jiruvided, however, that no person shall be entitled, in any case, to make and file such affidavit, exempting him from subpoenas as aforesaid, who shall upon tender of the usual fees of witnesses, in courts of record, refuse to be present and to give his deposition at his office or usual place of business, or, instead thereof, at his house or usual place of abode ; provided f ui'ther, that any person so present and giving his deposition at his office or usual place of biisiness, or, instead thereof, at his hoiise or usual jjlace of abode, who shall be de- tained four hoiu's from the time fixed for tlie taking of such deposition, or from the time to which the taking of the same may have been adjoiirned, may make affidavit that further detention Avould be seriouslj^ detrimental or hazardoiis to the welfare of the person or business in or under his charge ; and such affidavit having been made, a justice of the peace, court commissaries, notary public, or other authorized officer be- fore whom such deposition is given, shall thereupon adjourn further proceedings thereon to a future day. Sec. 593. — Proceedings to Determine Insanity — Examination hy Physicians. Whenever any resident of this State, or any person fi-om therein whose residence cannot be ascertained, shall be or be supposed to be insane, application maj^ be made in his behalf by any respectable citizen to the judge of the County Court, judge of the Circuit Court, or any judge of a court of record in and for the county in which he resides, or, in case his residence is unknown, the county in which he is found, for a judicial inquiry as to his mental condition, and for an order of commitment to some hospital or asylum for insane. The application shall be in writing and shall specify whether or not a trial by jury is desired by apjjlicant. On receipt of said petition the judge to whom it is adch'essed shall appoint two disinterested physicians, of good repute for medical skill and moral integrity, to visit and examine the person alleged to be insane ; and such physicians shall proceed without unnecessary delay to the residence of the person supposed to be insane, and shall by personal examination and inquiries satisfy themselves fully as to his condition and report the result of their examination to the judge. ... . . . Upon the receipt of the report of the examining physicians the judge may, if no demand has been made for a jury, make and enter his order of commitment to the hospital or asylum of the district to which the county belongs, or, if not fully satisfied, lie may make such additional investigation of the case as may seem to him to be necessary and proper ; and at any stage of the proceedings, and before the actual confinement of the person alleged to be insane, lie, or any relative or fi-iend acting in liis behalf, shall have the right to demand that the question of sanity be tried by a jury, and when such demand is made the judge shall forthwith enter an order for a jury trial. In ease a trial by jury is demanded, the forms of procedure shall be the same as in trials by jury in justices' courts, and the trial shall be in the presence of the person sup- posed to be insane, and his counsel and immediate friends and the medical wit- nesses. . . . County Jiid(/e may Order Insane Persons Confined. On receipt by the county judge of the petition provided for by section 1 of chapter 266 of the General Laws of 1880, such judge may, if in his opinion the public safety Al'l'KXDIX. G79 requires it, deliver to the sheriff of Lis county an order iu writing requiring him forth- witli to take and eonfine such insane or supposed insane person in some jdace to be specified, until further order of the judge ; and after the receipt by siicli judge of the report of the exiimining physicians provided for in said chapter, sucii judge may, in his discretion, deliver to sucli officer such order in writing reijuiring him forthwith to take such person into custody and keep him in some place to be specified, until tlie further order of sucli judge. The examining physicians provided for by said section 1 of said chapter 26G, in addition to the report required to be made by them by said section, shall state as follows : Has the patient any infectious disease ? In yoiu* opinion is he insane? ... If any relative or friend — being of a legal age and competent to perfoiTa the duties — of any person committed to any hospital for the insane shall request the warrant for such commitment may be delivered to and executed by him, he shall be l)aid his necessary expenses, not exceeding the fees and expenses now allowed to ■sheriffs according to law ; otherwise it shall be delivered to the sheriff, who, taking such assistants as the courts issuing such warrants may deem necessary, shall receive such insane person and convey him to the hospital. Revised Statutes op "Wyoming, 1887. Sec. 2287. — Ai)pJlcatio)i for Inquisition. If information in writing be given to the probate judge that any person in the -eonnty is an idiot, lunatic, or person of unsound mind, or an habitual drunkard, or ineajiable of managing, and praying that an inquiry therein to be had, the court, if satisfied that there be good cause for the exercise of its jm-isdiction, shall cause the facts to be inquired into by a jury. Sec. 2288. — Court may Act in Vacation. Such information may also be given in the vacation of said coiu't, to the judge therefor, in which event he shall call a special term of the court for the purj)ose of holding an inquiry whether the ijerson mentioned in such information be of unsound mind or an habitual drunkard, or not. Sec. 2289. — Person may he Brought into Court. In proceeding under this chapter the Probate Court may, in its discretion, cause the person alleged to be of unsound mind or habitual drunkard to be brought before the court. Sec. 2290. — "Whenever any judge of the Probate Court, justice of the peace, sheriff, coroner, or constable, shall discover any person resident of his county to be of imsound mind or an habitual dninkard, as in the first section of this chapter mentioned, it shall be his duty to make application to the Probate Court for the exercise of its jurisdiction, and thereupon the like proceedings shall be had as in the case of information by un- official persons. 1888. Chapter 85. Section 1. — That section No. 3765 of the Revised Statutes of "Wyo- ming be amended and revised so as to read as follows : Section 3765. — After the building herein provided for shall have been completed and accepted by the Board of Commis- sioners the board shall serve notice in writing uj)on the Boards of County Conunis- sioners of all the different counties in this Territory, which notice shall state that the asylum for insane at Evanston is now completed and ready for the reception and care of insane persons. Each Board of County Commissioners shall, after the receipt of such notice, cause all persons adjudged to be insane, and whose care shall have been thrown upon the coiinty, to be sent as patients to the Insane Asylum at Evanston, there to be kept and cared for at the expense of said coimty. And all insane persons having been sent to asylums outside of this Territory shall, upon the completion of said asyhnu at Evanston, and notice to the Board of County Commissioners as herein- before provided, be returned as soon as practicable, under an order of the respective Boards of County Commissioners, to this county, to be kept and cared for at the insane asylum at Evanston. 680 APPENDIX. Sec. 3764 (1887). — Siqjerintendent of Asylums — Qualifications and Duties. The Board of Commissioners shall elect one resident physician, who shall be the general supeiintendent of the insane asylum herein pro^dded for, subject at all times to the order and duties of said board, which shall have power at any time, whenever in their Judgment it shall be deemed i^roper and for the best interests of the Tenitory, to discharge and remove such superintendent. The superintendent so elected shall reside at the asylum, be a graduate in medicine, and receive a salary of eighteen hundred dollars per year, payable in advance in equal installments. He shall cause to be kept a fair and full account of all his doings and the actual business and opera- tions of the institution, and submit a monthly report to the Board of Commissioners. The supeiintendent shall employ all necessary help needed at the asylum, subject to the approval of the Board of Commissioners. Sec. 3766. — Paying patients, whose friends offer and will pay, or who have property to pay their expenses, shall be admitted to the insane asylum, according to the terms directed by the Board of Commissioners thereof ; but the insane poor shall in all re- spects receive the same medical care and treatment, and be given as wholesome food^ as is given to paying patients. iisrDE:^:. PAGE Aberration, mental, influence of, upon capacity of individual n. 112 Abortion, clinical evidences of : changes in maternal organism dm-ing preg- nancy, condition of utero-vaginal tract, genital discharges II. 472 stains upon bedding or clothing II. 475 criminally induced IE. 468 (a) medicinal measures : ergot, tansy, cotton-root, sa^"in, rue, yew, saf- fron, peunyroj'al, cathartics, apiol. chloride of iron II. 469, 470 (6) mechanical measures : blows, jolts, douches, tents, etc .11. 470 defined H. 467 dii"eet interference to produce : detachment of ovum, perforation of fetus, galvanic ciu-rent U. 471 evidences of criminal II. 477 that confiuement has occurred 11. 478 feigned 11. 478 infanticide II. 479 legitimately induced 11. 468 non-induced or spontaneous II. 467 post-mortem signs of 11. 475 relations of physicians, etc., to the patients in eases of I. 638 size of uterus and development of fetus 11. 477 stage of gestation when abortion took place II. 476 Abscess of testicle II. 628 Abuse, sexual, of children ; manustupration II. 545 Accident, death by drowning I. 128 hanging or strangulation I. 120 suffocation I. Ill disease the result of, in relation to insurance I. 5S5 in relation to insurance I. 583 Accident Cases, damages for loss of income II. 383 defined II. 377 inviolability of the person II. 378 negligence of injured party 11. 380 physical examination before trial II. 377 questions for medical expert II. 379 recovery of cost of medical attention 11. 384 ultimate and direct results of injiu-ies II. 380 Accident Insurance (see Insurance) I. 493. 583 Acetic Acid I. 490 081 682 INDEX. PAGE Acids, boracie, 'borie, eliromie, chromic anhydride, potassic dichromate I. 332 hydrochloric, muriatic I. 329- mineral » = 1. 326 nitric, aqua fortis = I. 330 sulphiuic, oil of vitriol I. 326 AcoxiTE, aconitin, aconitine, aconitia, aconitina I. 421 ACQUETTA DI PeRUGIA I. 496 Action, reflex II. 21 Acute Alcoholism II. 95 Acute Dementia II. 109 Adipocere I. 104 Adolescent Insanity II. 90 Affections of Memory II. 46 Age, determination of the- indications of I. 194 as determined hy skeleton I. 56 Age of consent I. 651 ; II. 517, 525 Agoraphobia . » , II. 45 Agraphia II. 268 Alalia II. 267 Alcohol, insanity due to II. 205- Alcoholic general i^aresis II. 97 insanity II. 95- hallucinations in II. 96 Alcoholism II. 59, 123, 205 habitual drunkards II. 152' Alealoidal and other Organic Poisons (see Poisons) I. 415' Alkaloids, animal (see Poisons) I. 475 mydi'iatic I. 427 Ammonia I. 324 Amnesic Aphasia II. 267 Amputations (see Sm-gery) II. 621 Anesthesia, cutaneous, in traumatic neuroses II. 339 feigned II. 403 sexualis II. 557 Anesthetics, administration of II. 598. never without assistant II. 594 to pregnant women II. 600 with witnesses, with female patients II. 595 bromide of ethyl, hj^drobromic ether II. 603 cause of death II. 595 chloroform, fatal narcosis II. 596 idiosyncrasy II. 598 dangerous narcosis, treatment of II. 599 death under II. 594 by suffocation from I. 113 indirect causes of II. 596 effect of, upon kidnej'S II. 597 ether, objections to II. 600 failure of, to produce results II. 602 nitrous oxide II. 603 statistics, reports, and cases <. II. 601 INDEX. G83 PAon Analysis, spectrum, of blood-stains I. 142 Anchylosis II. 621 Aneurism, case of mistaken II. 60(> diagnosis of II. 605 sm-gical malpractice in treating II. 60.5 Anoulah Gyrus of the brain II. 27 Antimony, antimony chloride, antimoniureted hydrogen, butter of antimony. I. 341 Aphasia, agraphia II. 268 amnesic and ataxic II. 267 apraxia II. 2Q[) bulbar and pseudobulbar affections of speech II. 281 cases of : BcA'en, Fillmore will II. 262 Parish will II. 261 cerebral centers in meclianism of speech II. 269 disorders of pantomime in II. 287 cases II. 289-296 dyslexia II. 272 forms of speech disorders produced by lesions II. 270 history and literature of II. 25i> interdiction of aphasics II. 261 measure of capacity II. 266 medico-legal aspects of II. 259 questions in connection with II. 263 mental disturbance in II. 261 status of motor aphasics II. 279 of sensory aphasics II. 27;> in verbal amnesia II. 277 in word-blindness II. 275 in word-deafness II. 274 motor or emissive II. 267 paraphasias or conduction aphasias II. 268 psychical blindness and deafness II. 268 sensory or receptive II. 267 simulated, mimetic, etc., affections of speech II. 285 speech disturbances, associated with insanitj' and epilepsy II. 283, 284 in (bearing on insanity) II. 47 testamentary capacity in II. 265 total II. 268 verbal amnesia II. 268 Aphemia II. 267 Apperception of the mind II. 19 Apraxia II. 269 Aqua Tofpana I. 350, 490 Arsenic, arsenic acid, arsenates, arsine, arseniureted hydrogen, siilphides. . . I. 380 arsenious acid, arsenious oxide, white arsenic I. 356 eating, Maybrick case . ■ I. 369 metallic I. 355 Asemasia II. 267 Aseptic and antiseptic sm-gery II. 590 Asphyxia, djTiamical I. 113 in di'o wiling I. 120 684 INDEX. PAGE Assaults, criminal (see Post-mortem Examinations) I. 33 indecent, upon children I. 649 ; II. 525 Association, benefit (see Insm-ance) I. 493 Asylum Physician, a mere custodian II. 147 Ataxia, ataxic aphasia II. 267 feigned ._ II. 402 Ataxiagram II. 315 Atheroma of the scalp 11. 609 Atropine, atroj)in, atropia I. 424 Autopsy (see Post-mortem Examinations) I. 25, 57 government regulation of I. 57 in death from electric shock II. 369 proper time for I. 36 Baby-farming I- 137 Belladonna I- 424 Benefit Association (see Insurance) I. 493 Bibliography, blood-stains I. 186 effects of electric currents II- 376 insanity and crime II- 214 insanity in its medico-legal relations II. 160 traumatic neuroses II. 352 Birth, child, number a woman may or should have = 11. 461 substitution and suppression of II. 459 viability of , II. 450 delivery, C^esarean section II- 456, 459 duties of physicians in II- 456, 466 premature labor, induction of II- 460 symphyseotomy II- 459 lactation H. 458 legal obligations of physician in recording II- 417 French Civil Code II- 418 legal procedure against physicians II. 465 obstetrics H- 459, 463 pregnancy, artificial insemination II. 439 conception, marriage and conception, interference to pre- vent conception II- 437 duration of gestation, its bearing on legitimacy II- 450, 453 extra-uterine = II- 440 laws of different coimtries regarding II. 453 multiple II- 446 past or present condition of II- 462 signs of II- 441 Hegar's II. 442 kiestein, ballottement II. 443 simulation of H- 444 sterility, relative and absolute II- 439 superf elation H- 446 puerperal fever, local inj;iries II. 457 state II- 456 Blindness, feigned II- 406 Blood, ai-terial, venous, menstrual I- l''^9 INDEX. G85 pa(;k Blood, chemical composition of I. 140 corpuscles I. 150, 171, 173 distinctions between liunian and other I. 172 fluidity of, after death I. 99 gi'avitation of, in capillaries after death I. 96 tests for I. 157-162 transfusion of II. 586 Blood-stains (see Wounds and Post-moi'tem Examinations) I. 139 action of alcohol, ether, chloroform, etc I. 150 ammonia, alkalies, bleaching agents, effect of heat I. 149 chemical agents upon blood I. 149 tincture of galls and of guaiacnm I. 150 water I. 149 age of I. 179 bibliography of I. 186 blood, chemical and physical properties of I. 139 chemical composition of I. 140 color of I. 139 distinction between human and other I. 172 Alley ease I. 179 dried I. 141 menstrual, arterial, and venous I. 179 blood-coloring matter I. 140 blood-corpuscles, measurements of I. 150, 171, 173 crystalline bodies obtained from I. 147 hpematin I. 141 ha?moglobin I. 140 crystals I. 148 spectroscopic appearances of I. 144 Stokes' baud I. 147 optical properties of I. 142 red corpuscles, comparative study of I. 150 number of I. 151 epithelium from vaginfe I. 180 illustrative cases of I. 180 microscopical examination of I. 167, 1 69 attempted distinction between blood of man and cow I. ISO man and duck ; man and sheep I. 181 blood-clots I. 168 cases : Commonwealth (w. Piper, State of Connecticut vs. Hayden I. 169 illustrative eases I. 170 materials found associated with blood I. 171 spores of porphjTidium I. 170 microspectroscope T. 143 examination by I. 144 seminal stains I. 184 spermatozoa I. 185 trichimouas vagina^ I. 185 spectrum analysis of I. 142 testing of suspected stains I. 152 appearauee of drops, etc., and of stains I. 155 686 INDEX. PAGE Blood-stains, corrosions upon metals, and drops and clots upon them I. 156 dye-woods and tanning materials, grease or tar, red paint, vegetable stains I. 157 preliminary examination I. 152 tests, chemical % I. 158 guaiacum I. 158, 159 hsBmin I. 158, 162 histological I. 158 microspectroseope I. 164 spectroscope I. 158 substances producing blue color I. 161 Bkain, anatomy of II. 22 arrested development of, idiocy II. 188 arterial supply to base of • II. 26 centers : psychic, sensory, motor, geniea;late, aphasic ; agraphic, aphasic, of lower extremity, of superior extremity ; motor, of face, of word- blindness, of hemianopsia, of word-deafness, of uneiate gyrus II. 24 cortical centers, angular gyrus II. 27 fibers, association of II. 22 course of pyramidal II. 23- mind, its dependence on activity of (see Mind) II. 1& tolerance of, to injury II. 19, 21 New England blasting case II. 21 weight of, Broca and Gratiolet II. 20 Bright's Disease, as a cause of insanity II. 60 as affecting insurance I. 537 Bromide op Ethyl, hydrobromic ether (see Anaesthetics) II. 603 Bromine, potassium bromide I. 334 Brucine, brucin, brucia I. 460 Bulbar and jiseudobulbar affections of speech II. 281 Bullets (see Wounds) I. 726 Burns (see Wounds) I. 288 CESAREAN Section II. 456, 459, 460 Calculus, vesical II. 628 Calomei^ mercuric and mercurous chloride, mercuric bichloride I. 400 Camphor I. 472 Cancroin I. 492 Cannabis Indica II. 33 Cantharides, Spanish fly I. 472 Capacity, mental II. 114 testamentary II. 115' Carbolic Acid I. 469' Carbonic Acid, death from suffocation by I. US' Cases : alcoholism (Von Krafft-Ebing's) II. 206 Alley (Leavitt), blood-stains I. 179 aphasic affections II. 289-296 Ayer vs. Eussell, insanity and false imprisonment II. 147 Baker vs. Baker, insanity and divorce II. 142 Banker vs. Banker, insanity and divorce II. 133 Banks vs. Goodfellow, insanity and will II. 118, 170 INDEX. 687 PAGE Cases : Bell vs. Bennett, insanity and annulment of marriage II. 1 36 Belliiigham, right and wrong test II. 228 beneficiary on life-insurance policy I. 507, 508 Beven, contract with aphasic II. 262 Billings, gunshot wounds I. 263 Blakely, insanity and will II. 12I Bliss vs. C. & P. R. R. R., habitual drunkard II. 158 Blodgett, habitual di-unkard II. 153 Boyd vs. Eby, lucid interval and insanity II. 113 Brady vs. jMcBride, insanity and will II. 117 brain, tolerance to injury, New England blasting ease II. 21 Briggs, gunshot woiinds I. 262 Brown vs. Howe, insanity and torts II. 143 Brown vs. Riggin, insanity and will II. 122 Bi-uin, wounds, self-inflicted I. 281 Budge, Mrs., knife-wounds I. 249, 259, 273, 277 Carter vs. Beckwith, claim against lunatic II. 142 Cherbonnier vs. Evitts, insanity and will II. 122 Colvocoresses, Captain, suicide I. 282 Commonwealth vs. Piper, blood-stains I. 169 Cramer, Jennie, poisoning, arsenic I. 381 death under anassthetie II. 594 delusions, insane II. 235-241 of rape II. 211 Dickie, commissioner in lunacy II. 139 Dickinson vs. Barber, degree of insanity II. 144 Dills vs. State of Indiana, compulsory expert testimony II. 150 Ducker vs. Whitson, contract with lunatic II. 130 Eddy, insanity and will II. 117 electric currents, burning '. II. 371 damages for iujiu-y or death and loss of income ... .II. 378-383 death from II. 368, 369 effects of II. 373-375 injuries from II. 365, 367 Erdmann's blood-stains I. 1 70 feigned diseases II. 399 insanity 11. 410 Fillmore, aphasia and testamentary capacity 11. 262 Fort Edwards, wounds, contused I. 269 Garfield (President), post-mortem examination I. 43 Gerhold vs. Wyss, insanity and divorce II. ] 36 German courts, attitude regarding divorce, etc., and insanity II. 133. 134 Greenwood cs. Klein, insanity and undue influence II. 126 Guiteau, insanity and crime II. 198 Gumbault rs. Public Administrator, lucid interval II. 113 Hall vs. Warren, lucid interval II. ] 1 3 hallucinations, historical II. 33 Hamilton cs. Third Avenue R. R., damages for mental distress II. 385 Harford vs. Singleton, insanity and breach of promise II. 132 Harris (Carlyle), professional confidences of physicians I. 625 688 /iVD^x. PAGE Cases : Hartwell vs. MeMaster, eeeentrieity and will n. 120 Heigham, wounds, gunshot . . ; I. 254 hermaphrodites II. 419 historical, of hereditary insanity .11. 58 Howe, insanity and torts II. 143 Hughes, wounds, incised I. 270 Hui'lehy vs. Martine, false imprisonment and insanity II. 147 hysterical H. 211 illustrating blood-stains I. 170-182 imperative concepts H. 45 insane motives H. 180 insurance — warranties and representations I. 499-504 Johnson vs. Ai'mstrong, insanity, undue influence, and testamentary ca- pacity II. 125 Jumel will, delusions and testamentary capacity II. 118 Kennedy vs. Standard Sugar Eefining Co., damages for mental distress. . .II. 386 Klock, wounds, gunshot I. 268 Lancaster Co. Bank vs. Moore, contracts and insanity II. 131 Lee vs. Scudder, alcoholism and testamentary capacity II. 125 Lewis vs. Lewis, insanity and annulment of marriage H. 136 life-insurance policy on limatic, recovery on II. 145, 146 Lilly vs. Waggoner, contracts and insanity II. 128 Lynch vs. Knight, damages for mental distress II. 387 Mclntyre vs. Giblin, damages for mental distress II. 385 Mclntyre vs. Sholty, torts and insanity II. 143 McNaughton, "right or wrong" test, crime and insanity II. 175, 218 MePherson, insanity and testamentary capacity ; II. 113 Mallon, wounds, gunshot I. 271 Manley's Executor vs. Staples, delusions and testamentary capacity II. 119 Mar.sh, alcoholism and testamentary capacity II. 124 Marvin, banki'uptcy and insanity II. 137 Maybi'iek, Mrs., poisoning, arsenic I. 357, 369 Mechanicsville, wound, contused, and fracture I. 268 mental distress, damages for II. 385 mere distress II. 387 sense of shame II. 386 m^istaken diagnosis II. 606 Mordaunt, puerperal insanity and divorce II. 135 Murphy, bankruptcy and insanity II. 137 Newton vs. Mutual Benefit Life Insurance Comj^any, insanity and insur- ance II. 147 O'Connor vs. Eempt, habitual drunkard II. 157 O'Shea, wounds, contused I. 251 paranoiac delusions II. 89 Parish, aphasia and testamentary capacity II. 261 Patterson, habitual drunkard II. 141 Peoy)le vs. Barber, mental responsibility and crime II. 233 Piper, blood-stains I. 169 Pomeroy, imbecility and crime II. 86 Prentis vs. Bates, eccentricity and testamentary capacity II. 119 INDEX. 689 PAGE Cases : Priteliai'd, poisouiiig, antimony I. 34S puei'j^eral insanity and crime II. 103 rape, senile attempt at II. 556 Eavacliol, insanity and crime 11. 184 Eawdon vs. Rawdon, insanity and divorce 11. 133 Riddle, Mrs., poisoning, arsenic I. 380 Riggin, delirium and testamentary capacity 11. 122 Rusk, contracts and insanity II. 129 sexual perversion II. 556 contrary sexuality II. 570 f etichisra, body II. 567 dress II. 56» hyperfesthesia sexualis II. 558 lust-murder II. 561 Shattuck, wounds, gunshot I. 281 Sherman, Mrs., poisoning, arsenic I. 350 Smith vs. Williamson, habitual drunkard II. 158 State ex rel. Setzer vs. Setzer, insanity and legitimacy II. 133 State of Connecticut vs. Hayden, blood-stains I. 169 Steenbergh, wounds, contused I. 275 Summers vs. State of Texas, power to compel expert testimony II. 150 Thompson, wounds, contused and lacerated I. 278 Tiehborne, identity I. 71, 192 traumatic hysteria II. 344 Underwood vs. Wing, sui'vivorship I. 236 Victoria Railway Commission vs. Coultas, damages for mental distress. . . II. 388 Wallis vs. Luhriug, undue influence and testamentary capacity II. 113 Watson, extreme age II. ] 17 Weitzel, insanity and bankruptcy II. 137 Welsh "fasting girl" I. 137 Weston, wounds, incised I. 260 Wharton, poisoning, antimony I. 347 Whiteehapel murders, identity of dead body I. 61, 75 Wightman vs. Wightman, insanity and validity of marriage II. 172 Williams vs. Goss, habitual drunkard II. 152 Young vs. Young, alcoholism and divorce II. 1 53 Castration II. 628 Catalepsy II. 51 feigned II. 401 Causes of insanity II. 57 Children (see Birth, Pregnancy, Sexual Perversion, etc.). age of consent: I. 651 ; II. 525 indecent assault upon I. 649 ; II. 525 limit of childhood II. 185 responsibility of, for ei'ime II. 1 84 substitution of, at birth II. 459 suppression of, after birth II. 459 Chloral, chloral hydrate I. 468 chloral habit, a cause of insanity II. 59 Chlorine, potassic chlorate I. 333 690 IXDEX. PAGE Chloeoform (see Anaesthetics) , I. 466 ; EC. 596 Cholix I. 492 Chorea, feigned II. 402 Cicatrices, identification by I. 72, 201 CiRCUMCislox (see Grenito-urLiiarT) H. 627 Claustrophobia (see Insanity) II. 45 Cleft Palate (see Sui"gieal Practice) II. 610 Cocaine I. 428 insanity due to cocaine habit II. 59, 205, 209 CocATDTsic Acid I. 428 CoccuLrs Indicus, picrotoxin I. 473 Codelst: I. 439 Colchicum, eolcMcine, colchicin, colcMcia, colchieina I. 430 Cold as affecting insurance I. 540 COLICA PlCTOROiI I. 394 Color -BLrsDNESs, feigned n. 408 C0M3IISSI0X in lunacy II. 138 appHeation for II. 142 traverse in finding of II. 142 CoJiMiTMEXT of the insane II. 138 CoioiiTTEE of estate, in lunacy n. 142 CoiiPEXSATiox of expert witness 11. 149 Competency of the insane to testify n. 173 Concepts, agoraphobia and claustrophobia 11. 45 insistent and imperative n. 44 case of imperative concepts II- 45 mental II- 28 normal and diseased II- 28 Concussion (see Wounds) I- 287 of the brain and of the spinal cord II- 298 CONTINE, conium, coniin, conine, conia, conieine, eonicina I. 432 Consumption as affecting insurance I- 529 Contagious Diseases, duties of physicians and sm-geons as to I. 633 Contracts, in legal relations of physicians and surgeons I- 604 insanity as affecting II- 173 Contracture (see Surgical Practice) II- 621 Contusions (see Post-mortem Examination and Wounds) I. 32, 244 Convulsions (see Epilepsy) II- 223 feigned II- 399 Copper, cupric suli^hate I- 404 Coroner's Inquest (see Post-mortem Examination) I. 57 Corpse, identity of (see Identity) I- 32 Corrosive Poisons (see Poisons and Post-mortem Examination) '. I. 33 Corrosive Sublimate I- 400 Courts of Law, rulings of (see Laws, Cases, etc-). capacity to know right from wrong, charge of Chief -Justice Shaw II. 231 decisions recognizing mental disease .* II- 251 delusions as a defense for crime II- 230 legal views of State courts regarding impulse II- 244 Craniology II- 'i^ of criminals II. 183 INDEX. 691 PAGE €retinism TT. 85 Orime, deaf-miitism and II. 190 imbecility aiul II. 189 inherited and insane tendencies II. 182 insane impulses toward II. 48 intoxication as an excuse for II. 205 resp(Hisibility of children for II. 184 sexual II. 525 signs of degeneracy II. 184 Criminal, age of II. 185 assaults I. 33 craniology and skull capacity of II. 183 legal relations of physicians and surgeons to I. 636 lunatic II. 182 Criminal Kesponsibility (see Responsibility) II. 217 Croton Oil I. 471 Cutaneous Anaesthesia II. 339 Darwinian Tubercle I. 70 ; II. 73 Datura Stramonium I. 427 Deadly Nightshade I. 424 Deaf-mutes, mental capacity of II. 158 deaf -mutism and crime II. 190 feigned deafness II. 408 Death, autopsies, government regulation of I. 57 causes of, medical testimony regarding, in insurance cases I. 593 condition of blood at approach of I. 88 cooling of body after I. 90 coroner's inquest I. 57 decomposition and putrefaction I. 99 adipocere, formation of I. 104 chronological order of I. 105 external appearances of I. 107 mummification and saponification I. 105 determination of I. 58 drowning, death by I. 88 apiiearance of mucous membrane I. 102 asphyxiation I. 120 changes in appearances of features, of viscera I. 101 coldness of the body I. 121 condition of hands and feet I. 122 contents of gall-bladder I. 102 effect of temperature on decomposition I. lo:} effusion of fluid into cavities I. 1 02 fluidity of the blood after death I. 99 injuries to body in inmning water I. 129 internal examination I. 123 nature and depth of fluid I. 130 paleness of the body I. 121 pulmonary apoplexy and neuro-paralysis I. 121 putrefaction, pressure of gases evolved in I. 100 putrefaction after drowning. I. 09 C92 INDEX. PAGE Death by drowning, relation io life insurance I. 58& situation of the tongue I. 122 water in lungs and stomach I. 100, 126 whether the result of accident, suicide, or homicide I. 128 due to violence I. 58 electricity, death by I. 134 frost erythema I. 97 gi-avitation of blood in capillaries after I. 96 hanging and strangulation, death by I. 116 accidental I- 120 appearance of body I. 118 occurring before or after death I. 117 suicidal I- 116 heat or cold, death by I. 131 burning, consequences of I. 133 excessive heat I. 132 freezing I. 132 hue of blood I. 132 hypostases, post-mortem I. 97 spontaneous combustion I. 133 identity of dead body I. 59 accidental or voluntary alterations I. 193-196 age I- 64-66 anthropological aids I- 59 cases, Whitechapel murders I. 61, 75 Tiehborne claimant - I. 71 cicatrices I. 72 Darwinian tubercle !• 70 deformities I- 72 featui'es, gnathic index I. 60, 70- hair, color and character of I. 70 diameter of I. 74 human and animal I. 7-4 nose I- 61 occupation during life . , I. 73 photogi'aphy, value of I. 59 race characteristics I. 60 scars I. 71 sex, of mutilated or decomposed bodies I. 61 of skeleton I. 63 stature I- 68 and size of races I. 60 figure carre for determining I. 69 length of femur as determining I. 68 Orfila's and Sue's tables I. 68, 69 tables of details to be noted in identification I. 75 teeth, development of I- 67 tattoo marks I. 72 medico-legal aspects of I. 57 period at which occurred I. 96 poisoning, death from, by illuminating-gas I. 97 INDEX. Guar PAGE Death, septicemia, death from I. *M' signs of I. 87, 91 changes in the eye I. 02 from narcotic poisoning ; I. 9.5' rigor mortis I. 93-95, 99' softening of muscles and tissues I. 93; starvation, deatli by I- 134: baby-favniing I. 1 37 fades liij)j)t>cr(ttica I. 137 Welsh "fasting girl " I. 137 suffocation, death by, manner produced I. 108' accidental I. Ill anaesthetics, by I. 1 1 3- carbonic acid, by I. 115 dynamical asphyxia Ijy noxious gases I. 113 homicide by I. 111. 112 internal occlusion of air-passages I. Ill post-mortem appearances of I. 1U9 sewer-gas and sulpliureted hydrogen I. 115 smoke, by I. 113 smothering, bj" I. Ill vitiated air, by I. 112 suicide by carbolic acid I. 88 siispended animation, by T. 88, 89 suspension of respiration, by I. 88- sjnicope, by I. 88- tests showing I. 95 Decomposition (see Death and Post-mortem Examination) I. 35 effects of temperatm-e upon I. 99 Delirium (see Insanity), acute II. 103 tremens II. 95 Delusions (see Insanity) II. 35 as a defense for crime II. 230 as betrayed in dress II. 39 as symptoms of insanity II. -10 associated with hallucinations II. 39 case of, i n paranoia II. 36 concealet 1 II. -12 definition of II. 35 erotic II. 44 fixed II. 42 formation of 11. 39 genesis of II. 40 persecutory II. 41 religious 11. 35 case of II. 43 sane or insane II. 35, 2.34 Swedenborg's and Luther's II. 39 systematizetl or unsystematized II. 39 Dementia (see Insanity) II. 46 acute II. 10» ,t394 IXBEX. PAGE De:mentia, forms of II. 108 paretic II. 110 illusions due to paretic dementia II. 35 primary II. 109 senile II. 109 Dentists, professional standing of, before the law I. 643 Detection of metallic poisons I. 54 Developmental Ugliness II. 86 Diathesis, insane ,. II. 49 Digitalis, digitalin, digitouin, digitoxin, digitalein I. 463 Diploma as showing qualification of physicians and surgeons I. 637 Disease, Bright's I. 537 cold I. 540 consumption I. 529 dyspepsia I. 534 ■eye, diseases of the I. 539 fits I. 534 headaches I. 540 lieart disease I. 535 hemoptysis I. 532 in relation to life insurance (see Insurance) I. 493 liver, disease of the I. 538 mastoid II. 612 narcotics I. 551 • opium I. 551 rheumatism I. 536 ■the result of accident I. 585 tonsilitis s I. 538 'Dislocations (see Wounds) I. 294 Distress (see Mental Distress) II. 385 X>iV0RCE (see Marriage and, Insanity and). by consent II. 522 causes for, adultery II. 522 arising after marriage II. 521 before marriage II. 520 cruelty II. 521 desertion II. 522 habitual drunkenness II. 522 ill treatment II. 521 impotence II. 497-503, 520 insanity II. 133, 521 cases of II. 133-136 loathsome diseases II. 522 gonorrhea II. 505 syphilis II. 509 condonation and recrimination as defenses II. 523 procedure II. 519 testimony in divorce suits II. 523 Dreaming II. 51 Drowning (see Death) I. 88 ■J)RUNKARDS, habitual (see Insanity) II. 152 IXDJ'JX. 095 DiTY of medical examiners for insurance companies I. "juD of i)liysicians ami siirj^eons as to coiita<^ious diseases I. ii'S.i goiiorrlical disease II. auS Dy.slkxi A II. '2~'2 Dyspepsia us affcctiiif^ insurance I. 'I'-'A Eating of Iminan flesli (see Insanity) 11. 4'.J EcjCKNTKicprY as affecting testamentary cai)acity II. 1 1 IJ EcOHYMOsis (see Post-mortem Examinations and Wounds) I. ^i"), 244 P^CHOLALIA (see Insanity) II. 74 Elkctric Currents of high power TI. '.'.C/.i bibliography II. ;j7t) (lea th fi'om I. 1 .■J4 ; II. '.'AH autopsies II. ;jG9 cases II. :]m, 309 effects of, upon the human body II. 304 charges that do not kill II. 30.5 . cases II. 30;)-307 electric burning and ease of II. 371 falls and other injuries due to II. 37 1 medical electricity, accidents from II. 372 recent legal decisions II. 373 Augusta Railway Co. r.v. Andrews II. 374 Burt vs. Douglas County Street Eailway II. 373 Clements rs. Louisiana Electric Light Co II. 373 Colorado Electric Co. r.s-. Lubbers II. 374 Electric Railway Co. rs. Shelton II. 37.") Krantz vs. Brush Electric Light Co II. .374 Piedmont Electric Illuminating Co. vs. Pattesou's Administrator II. 37.1 Southwestern Telegraph and Telephone Co. rs. Robinson 11. .373 Embalming as affecting putrefaction I. 1 ii4 Embolism, fat, as a mishaii of surgical practice II. oS."), 0(1.3 Emotion, disturbances of II. 4S Empyema II. 014 Epidtdy.mitis and crime II. 1 99 and idiocy II. ]8S and indjecility II. 2(10 and violence II. 2't() as a cause of sterility II. r)04 defined II. 199 epileptic insanity II. 93 feigned IL 200, 399 morbid states after convulsions II. 9.'i Epilepsy II, 223 and aphasia II. 2S4 Epithelium from vagina (see Blood-stains) I. ISO Erytheaia, frost (see Death and Post-mortem Examination) I. 97 Ery'titroxylon Coca I. 42S Ether, hydrobromic (see Anipsthetics and Surgical Practice) II. 003 Ethylidendiamin and ethylendiamin I. 491 Eustachian Tube, catheterization of II. 012 ExA:\riN,vTioN, expert I. 591 696 IXDEX. PAGE ExAMiKATiON, expert, in indecent assault I. Qb5' of insane criminals 11. 213- physical, in accident cases II. 377 post-mortem I. 25' Examining Boards, diplomas of physicians and surgeons from I. 598- Excise Laws, relations of physicians and surgeons to I. 638- Experiments on effects of ptomaines I. 485 Experts, medical II. 13 avowal of uon-expertism II. 148- compensation of I. 614 ; II. 149' criminal cases or de lunafico inqidrendo II. 15, 148- duties and resiionsibilities of II. 13, 148- English laws regarding II. 13 evidence, in surgery cases II. 574 value of II. 17 examination of applicants for insiu'ance I. 591 plaintiff in accident cases II. 377 hypothetical questions II. 15, 148 impartiality of II. 148- qualifications of II. 148, 177 questions for, in accident cases II. 377 infanticide cases II. 47& use of books in court II. 14^ Extravasation (see Woimds) I. 298 Eye, diseases of, as affecting insurance I. 539 feigned II. 40& hysterical blindness II. 407 Facies Hippocratica I. 137 Fees, of medical experts I. 614 ; II. 149 of physicians and surgeons I. 604, 608, 614 Feigned Diseases of the mind and nervous system 11. 391 insanity II. 410 difficulty of feigning II. 411 special signs justifying suspicion II. 413 instruments for detecting 11. 391 manliugering II. 392 danger to manlingerer II. 396 motives for, and fi'eqiiency of II. 391, 392 paranoia, paretic dementia, and dementia II. 413, 414 pension-office statistics II. 392 rules for detecting II. 395 simulated motor symptoms and methods of detection, paralysis II. 397 convulsions, epilepsy II. 399 contracture, catalepsy II. 401 tremor, ataxia, chorea .* II. 402 simulated sensory symptoms and methods of detection, antesthesia II. 403 blindness, hysterical blindness II. 406, 407 hemeralopia, color-blindness II. 408 hyperfesthesia and pain II. 405 speech disturbances II. 410 sjTinptoms most easily feigned II. 414 ISDKX. G97 PAGE Feigned Diseases, etc. , symptoms impossible to feign II. 395 deliberately produced II. 396 genuine, cause feigned II. 390 Fetichis.m, body, and cases II. 507 dress II. 508 cases II. 569 erotic II. 506 Fibers (see Hairs) I. 187 Finger marks (see Post-mortem Examination) I. 32 impressions (see Identity) I. 534 Fistula, lacteal II. 014 Fits as affecting insurance I. 534 FoLiE A Deux II. 95 FOLIE CiRCULAIRE II. 91 Foxglove I. 403 Fractures (see Wounds and Surgical Practice) II. 573 amputations II. 021 anchylosis II. 021 contractures II. 021 deformities following II. 014 extremities II. 014 gangrene following II. 017 hip disease in children II. 019 injuries of hip-joint II. 618 lower end of radius II. 010 near elbow II. 015 neck of humerus II. 015 resection of knee II. G2(J tenotomies and myotomies II. 021 wounds and f laetures I. 290 Frost Erythema I. 97 FuGiN I. 492 Oadinixe I. 492 •Gelsemium, gelsemine, gelsemic acid, gelsemin, gelsemia I. 434 General Paresis, alcoholic (see Paretic Dementia) II. 97 Oenito-urinary and venereal affections II. 497 gonorrhea, lu'ethritis II. 505 duty of physician advising marriage II. 508 clTcft s of, in producing sterility II. 508 upon offspring II. 508 iipon relations of sexes during man-iage II. 507 gonococcus II. 505 modes of infection II. 505 impotence in the male II. 497 diseases of the kidneys, bladder, etc II. 502 glycosuria II. 501 malformations II. 498 masturbation II. 502 mental conditions 11. 500 impotence in the female TI. 502 hysteria II. 503 698 INDEX. PAGE Gexito-urixary, etc., impotence in tlie female, imperforate hymen II. 503 malforuiations 11. 502 vagiuismus II. 50i> sterility in tlie male II. 503- blockiug of vasa clef erentia II. 504 epididjTiiitis II. 504 sterility in the female II. 504 absence of ovaries II. 504 acidity of secretions II. 505- siu'gical practice and malpractice II. P>'l0' abscess of testicle II. 628 castration 11. 628 catheterization and other methods II. 626 permanent II. 627 eircimicision II- 627 hydrocele II- 627 vesical calculus II. 628 syphilis , II- 50& ' CoUes's law II. 514 congenital and acquired ; II. 510 ground for divorce II. 513^ infection from choc en vctonr II. 512 intermittence of lesions II. 514 miscarriages as evidence of 11. 514 modes of infection II. 50D GoNOCoccus II. 505- presence of, in objects of~rape II. 536' GoxoRRHEA (see Genito-uriuary and Venereal Affections) II. 505 Grubelsucht (see Insanity) II. 44 GrxsHOT WouxDS (see Wounds and Surgical Practice) I. 252 ; II. 607 Habitual Drunkards, mental capacity of II. 152: cases II- 152-1.58 H.€;jiATiN I- 141 H.EMix I. 158, 162 HAEMOGLOBIN I- 140 Hairs and Fibers I. 70-74, 195, 196' body, hair from human I- 187 diameters and markings of I- 187-189- found upon -weapons I. 187 microscopical ajipearance of I. 188 silk, wool, flax I. 189- Hallucinations II. 30 auditory II. 31 definition of H. 30 due to alcohol, belladonna. Cannabis Indiea, hypnotic suggestion II. 33- solitary confinement H. 33 forms of insanity in which hallucinations appear II. 34 found alone and together H. 33- historical examples of II. 33 mechanism of 11. 30 of feeling II. 32; INDEX. G'J'^ Hallucinations, olfaetive II. 32. sensorial disturbances II. ;J2 unilateral II. 'M visual II. ;i(i Halogens, tho I. 'ssa ■ HANDWHiTiNri, insane, change in character of II. T-t Hanging (see Death by Hanging) I. \\(l- Harelip (see Surgical Practice) II. Oii!>"' Headache as affecting insurance I. 540' Health, in relation to insurance I. 511-al ^ family record I. ')a\ habits as affecting I. 541 occupation as affecting I. 55(5 sound I. 519 tables of mortality, etc I. 511, 512, 530, 550, 551, 557 wholly disabled I. 587^" Hellebore I. 460 ' Hemeralopia, feigned II. 408 • Hemlock I. 432" Hemophiliacs II. 58ff' Hemoptysis as affecting insurance I. 532: Hemorrhage as a mishap in surgical practice II. 586' Henbane I. 427' Heredity, as a cause of insanity II. 5.H' of criminal instinct II. 59' Hermaphrodite II. 418' Hernia (see Surgical Practice) II. G2.> cure of 11. 624 disturbances following operations II. 62.v hysterical atony simulating II. 624 Hip Disease in children II. 61!» History of life insiirance I. 493' Homicide (see Death, Post-mortem Examinations, Wounds, etc.). by drowning I. 128- suffocation I. Ill, 112 defined I. 24;;- Hydrocele II. 627 Hydroparacumaric Acid I. 48!V Hymen, anatomical changes induced by coitus II. 528. imperforate, as cause of impotence II. 50.'i' Hyoscyamus, hyoscyamine, hyoscine I. 427 Hyper.'esthesia Sexualis II. 557' Hypnosis and auto-hypnosis in eases of rape II. 541 hallucinations due to II. 33' liypnotic influence II. 212' illusions due to II. 3.>' Hypothetical Question (see Expert) II. 14S. Hysteria (see Insanity) II. Olf: cases II. 211 hysterical atonj' simulating hernia II. 62+ insnnitv II. 2()!> 700 INDEX. PAGE Hysteria, mercurial I. 399 responsibility 11. 210 Identity of the Dead Body (see Death) '. . . .1. 32, 59 determination of I. 60-73 Identity op the Living I. 191 .aecideutal or volimtary alterations in appearance I. 3 93 age, determination of I. 64, 194 ■cicatrices I. 171, 193 ■deformities I. 72, 193 ■disease, effects of I. 193, 194 finger-nails I. 196 liair, changes in I. 195 classification of I. 196 decoloration of I. 196 head, contigiiration of I. 195 insanity, results of I. 193 labor, manual or other, signs of I. 193 loss of limbs, teeth, or hair I. 193 pigment bleaching I. 193 teeth I. 195 trophic changes I. 193 finger and foot impressions I. 204 Galton's method I. 206 right- and left-handedness I. 207 significance of footprints I. 206 general appearance I. 21.S handwriting, identification bj' means of I. 203 history and experiences I. 228 incriminating circumstances I. 228 mental traits I. 226 mistaken identity I. 30, 191 recognition by pistol-flash I. 191 physical j)eculiarities I. 221 skin lesions and their results I. 200 cicatrices I. 72. 201 age of I. 202 diseases, evidences of I. 200 indelibility of marks I. 202 tattooing I. 72. 202 .-stigmata of occupation I. 73, 197 hands I. 198 recognition of changes due to occupation I. 1 98 suggestions as to examination I. 207 Bertillon's methods I. 208 Smart's and Greenleaf's methods I. 211 unreliability of evidence I. 192 Tichborne case I. 71 , 192 Idiocy, acquired II. 80 and alcoholism II. 80 and epilepsy, and paralysis II. 188 and heredity II. 188 INDEX. 701 PAOK Idiots, basis of mental expression of II. 84 c'l'iuiiology of II. 81 defective bruin development of II. 188 mental capacity of II. 84 mici'oeephalous II. 80 l)alatHl arch, deforaaity of II. 81 pliysical peculiarities of II. 80 ]iro}ifiiatliisin II. 81 sexual anouuilics in II. 85 speech of II. 84 suture, premature closing of II. 81 Illusions (see Insanity) II. 34 definition of II. 34 differentiation of II. 34 due to alcohol 11. 35 confusional insanity II. 35 hypnotic suggestion II. 35 paranoia II. 35 paretic dementia II. 35 Imbecility (see Insanity) II. 85 Imperative Concepts (see Insanity, Morbid Impulses) II. 44 cases of II. 45 Impotence (see Genito-urinary) II. 497 Impulse (see Insanity). maiiiacal II. 250 morbid II. 49 sexual II. 49 uncontrollable n. 44, 188, 191, 243 Incest (see Sexual Crimes) II. 547 anomalous psychical state leading to II. 548 defined II. 547 origin of aversion to II. 548 punisliment of II. 548 Indecent Assault upon children I. 649 accused (the) of I. 652 age of consent I. 651 ; II. 525 definition of I. 649 examination I. 655 false accusations I. 653 legal aspect of I. 649 penalty for I. 651 severity of I. 653 varieties of I. 651 Indecent Exposure (see Sexual Crimes) 11. 550 Indigo-blue I. 489 Indol, indoxyl, indirubin I- 487 Infanticide (see Abortion) II. 467, 479 criminal causes of death 11. 491 drowning 11. 493 fracture of skull • II. 494 neglect n. 495 702 INDEX. PAGE. IxFANTiciDE. Criminal causes of "death : precipitation into a vault II. 493- strangulation II. 492 suffocation II. 491 wounding II. 494 defined 11. 479 natui'al causes of death in new-born II. 48& accidents and injuries II. 49(> asphyxia II. 489 fetal disease 11- 48^^ malformation II. 488- maternal disease II. 491 questions for expert 11. 479' air in alimentary canal II. 486- artificial insufflation II. 484 atelectasis 11- 485 cardiac movements II. 486- child, cause of death II. 488 has it cried 11. 485- how long been dead II. 487 how long did it live II. 486- was it dead or alive at bii-th II. 482 was it mature II. 480- was it prisoner's II. 482 hydi'ostatic test II. 483 prisoner, has she been recently delivered II. 480 pulmonary docimasia II- 485 putrefaction II. 484 solidification II. 485- Wreden's test 11. 486 Inherited insane tendencies (see Insanity) II. 180 IxoRGANic Poisons (see Poisons) I. 322 IxsA>'E, the. appearance and conduct of II- '*^ appreciation of nature of act, etc., by II. 232 ai>i)i'^li^iii^ioii or removal of II. 142 as witnesses II- 137 attitude of II- '5'6 capacity of, general questions relative to II. 114 bankruptcy II- 137 cases II- 137 breach of promise II- 132 contracts H- 128, 172 cases II- 129 deaf-mutes II- 158 delusions II- H^ cases II- 118 disease H- 120 cases II. 121-125 divorce and anuTilment II- 133 cases II- 134-136 INDEX. 70;; PACK Insane, llie. Capacity of, general questions relative to : eccentricity II. 119' cases II. 120 general symptoms incapacitating II. lli> impeachment oi" public officer.s II. 144 influence of general diseases II. 1 20 legitimacy II. 133 marriage II. 131, 171, 518 old age and dementia II. 1 1 <"> cases II. 117 partnership, dissolution of II. 144 suicide II. 128 testamentary capacity II. 115- undue influence II. 1 25, 172 commission on II. 138 Dickie case II. 139 retrospective finding of a jury II. 141 traverse in fliuling of II. 142" application for traverse II. 142 commitment of II. 138 committee of estate of II. 142 competency to testify of II. 17.3 contracts of II. Vl^ deeds and other instruments of II. 114 dehisions of II. 234 dress of II. 78 emotions and will of II. 242 evidences of design in II. 232 examination of II. 150 liability of custodians of II. 147 for ci\dl damages of II. 172 libels and slanders by II. 143 maltreatment of II. 147 motive or absence of motive in II. 180, 234 museidar condition of II. 78 progeny of II. 58 responsibility of II. 128 restraint of II. 142 testamentary capacity II. 115 torts by II. 143 writing of II. 74 Insane Diathesis II. 40 Insane Impvlses II. 4s Insanity, acute mania II. 60 adolescent II. 90 alcoholic II. 95, LV_> alcoholism II. 50 habitual drunkards II. 152 cases of II. 152-158 alternating II. 91 aphasia II. 259-29C» 04 IXDEX. PAGE Insanity, bedsores in II. 79 bibliography and index II. 160-167 capacity (see Insane, capacity of) II. 114 eases beai"ing on insanity : aleoholismCVon Ki-afft-Ebing's) H. 206 aphasic affections II. 289-296 Ayer vs. Enssell, false imprisonment II. 147 Baker vs. Baker, divorce II. 142 Banker vs. Banker, divorce II. 142 Banks vs. Goodfellow, testamentary capacity II. 118, 170 Bell vs. Bennett, annulment of marriage II. 136 Blakely will II. 121 Bliss vs. C. & P. E. R. E., habitual drunkard II. 158 Blodgett, habitual drunkard II. 153 Boyd vs. Eby, medico-legal ; lucid interval II. 113 Brady will II. 117 brain tolerance to injiiry, New England blasting 11. 21 Brown vs. Howe, torts II. 143 Brown vs. Eiggin, will II. 122 Carter vs. Beckwith, contract II. 142 Cherbonnier vs. Evitts, will II. 122 delusions, insane II. 235-241 Dickie, commission in lunacy II. 139 Dickinson vs. Barber, degree 11. 144 Dills vs. State of Indiana, expert fees II. 150 Ducker vs. Whitson, contract II. 130 Eddy will II. 117 Fillmore, testamentary capacity II. 262 Gerhold vs. "Wyss. divorce II. 136 German courts, divorce II. 133, 134 Gombault r.s. Public Administrator, medico-legal; lucid interval II. 113 Greenwood vs. Klein, imdue influence II. 126 Guiteau, crime II. 198 hallucinations II. 33 Hartwell r.v. M'Master, testamentary capacity II. 120 historical lieredity II. oS Howe, torts II. 143 Hm'lehy vs. Martine, false imprisonment II. 147 hysterical II. 211 imperative concepts II. 45 insane motives II. ISO Johnson vs. Annstrong, testamentary capacity II. 125 Jumel will, testamentary capacity II. 118 Lancaster County Bank vs. Moore, contract II. 131 Lee r.s-. Seudder, testamentarj' capacity 11. 125 Lewis vs. Lewis, annulment of marriage II. 136 life insurance, recovery of II. 145, 146 Lilly vs. Waggoner, contract TI. 128 :McIntyre vs. Sholty, torts TI. 143 McXaughton, " riglit or wrong " test II. 175. 218 McPherson, testamentary capacity II. 113 INDEX. 70,3 PAGE Insanity, casea bearing on : Mauley's Executor r.y. Staples, testamentary capacity II. 119 Marsh, testamentary capacity 11. 124 Marvin, bankruptcy II. 137 Mordannt, divorce II. 135 Muri)liy, bankruptcy II. 137 Newton vs. Mutual Benefit Life Insurance Co., insurance II. 147 O'Connor vs. Rempt, habitual dnnikard II. 1.17 paranoiac delusions II. s'.> Parish, testamentary capacity II. 2')! Patterson, habitual drunkard II . 141 People vs. Barber, mental responsibility II. 233 Pomeroy, crime II . SO Prentis vs. Bates, testamentary cajjacity II. 119 puerperal, and crime II. 103 Kavachol, crime II. 184 Kawdou vs. Rawdon, divorce II. 133 Riggin, testamentary capacity II. 1 22 Rusk, contract II. 12!) Setzer vs. Setzer, legitimacy II. 1 33 Smith vs. Williamson, habitiuil druidvard II. 158 Summers vs. State of Te.xas, expert fees II. 150 Wallis vs. Luhring, undue influence 11. 113 Watson, testamentary capacity II. 117 Weitzel, bankruptcy II. KiT Wightraan vs. Wightman, marriage II. 172 Williams vs. Goss, habitual drunkard II. 1 52 Young vs. Young, divorce II. 153 causes of : alcoholism II. 50 Bright's disease II. (iO cardiac lesions II. (iO child-bearing and illegitimate pregnancy II. (iO, (il cocaine, chloral, or 02)ium liabits II. 5!) depletion II. (iO direct and iiulirect II. 5!) emotional II. 51) environment II. 5!) excessive se.xual excitement IT. (U feigaiing II. (U fright II. (il grief IT. (il heredity, historical cases II. 5S injuries to the brain II. (il intracranial disease II. (12 la grippe II. (io masturbation II. ()(• overwork II. 5!) phthisis II. ()() predis])osing II. 51) rheumatism II. GO 706 INDEX. ■ PAGE Insanity, causes of : septic poisoning II. 61 shock II. 61 syphilis II. 59 uterine and ovarian disease II. 60 classification of II. 54 convulsions in II. 78 course and termination of II. 62 eraniology of II. 73 curability of II. 62 cutaneous anaesthesia in II. 78 death from exhaustion in II. 62 definitions of, legal II. 53, 178 medical, by Bucknill II. 53 Hamilton II. 54, 56 Maudsley II. 53, 57 Spitzka II. 53 Von Krafft-Ebing II. 55 d.elusional (primary) II. 86 drunkards, habitual II. 1 52 epileptic II. 93, 223 ■epochal II. 55 expert witnesses II. 113, 148 case, Dills vs. State of Indiana II. 150 feigned II. 410 hallucinations II. 30 heart failure in II. 63 ieredity as a cause of II. 58 inherited tendencies II. 1 82 of criminal instinct II. 59 homicidal II. 45 Irypnotism II. 212 hallucinations due to II. 33 illusions due to II. 35 liysterical II. 48, 50, 93, 209 Ja grnndc hi/sterie II. 209 responsibility of hysteric II. 210 insane tendencies in II. 182 intellectual II. 86 lucid intervals in II. 222 -mania II. 93, ]00 mattoids II. 52 medico-legal aspects of • II. 19 commission on ^ commitment of / (see Insane), committee of estate of ' legal definitions ; general II. 53, 1 78 degree of insanity II- 144 English decisions II. 1 79 German decisions II. 1 78 judge's charge II. 178 L\DEX. 707 PAGE Insanity. Legal definitions, etc. : of lucid intervals, uon compos /«('/( //x, unsoundness of mind II. 1 1 :< province of the court II. r)4 medical definitions II. ')'.i-')7 medical expert II. 11."! megalomania II. >i7 melancholia 11. Oi), 98, 191 memory, affections of II. 4G, 47 monomania , II. 86 moral II. liUU, 252 morbid desires II. 49, .")i ' morbid impulses II. 1 SO, 191 , 242 imperative concepts II. 44 cases of II. 4.") neurasthenia IT. 211 paranoia II. s(i paretic dementia II. (59 partial II. 113, 224 periodical II. 91 physical signs of : II. 70 bones, brittleness of II. 79 brain, appearance of convolutions of II. G7 asymmetry of II. (57 atrophy of II. (is configuration of II. 6.1 hypera?mia of II. GS increase in size of II. G8 lesions of the blood-vessels of II. GS meningeal inflammation II. Git microcephalous (Ireland) II. G7 morbid anatomy of, in acute mania, melancholia, and paretic de- mentia II. 69 specific gravity of II. 65 ■weight of II. 6.") in imbeciles and idiots II. G() digestion and appetite II. 79 «ar II. 7S eye II. 7S secretion of tears II. 79 face, expression and furrows in II. 7.'j ■ skin in II. !»7 teeth in II. 7;> temperature in II. 79 tendinous reflexes in II. 7S microscopic appearances of nervous tissue II. G9 trophic disorders in II. 79 urine in II. 79 post-febrile II. 107 after typhoid II. 108 prognosis of IT. 63 puerperal, and cases IT. 103 708 IXDEX. PAGE IssANnTT, quenilent II. 88 reasoning II. 91 somatic II. 55 speech distm-banees associated with aphasia II. 283 suicidal II. 45 symptoms of, favorable and unfaA'orable (tabulated) II. 64, 65 total II. 222 traumatic II. 105 after surgical operations II. 107 due to .slight shocks II. 105 loss of memory in II. 107 traverse II. 142 application for II. 142 case, Baker rs. Baker II. 142 Verrucktlteit, priinare II. 56' sensorieUe II. 3-t IxSA^JiTT AivD AxNULMEKT OF IMakkiage (see Insane, capacity of) II. 135- marriages contracted in e.xtrcini>< II. 135 cases, Lewis rs. Lewis II. 135 BeU vs. Bennett II. 136 IxsAXiTY AST) Bankruptcy (see Insane, capacity of) II. 137 cases, Marvin, Murphy, Weitzel II. 137 IXSAXITY AND BREACH OF PROMISE II. 132 case, Harford vs. Singleton II. 132 INSANITY AifD Crime (see Crime and Responsibility) II. 175, 217 bibliogi-aphy of II. 214 examination of insane cidminals II. 213 expert testimony regarding II. 177 heredity of criminal instinct II. 58, 59 individual responsibility II. 213 insane criminals 11. 182 relationship between II. 176 special forms of insanity in relation to crime II. 184 alcoholism II. 59, 1 23, 205 ei)ileptic insanity II. 199 Guiteau case II. 198 moral insanity II. 200 paretic dementia II. 202 toxic insanitj'^ II. 205 INSANITY AND DIVORCE II. 133, 521 cases : Banker vs. Banker II. 133 Gerhold vs. Wyss II. 136 Le^^is vs. Lewis II. 1 36 Mordaunt II. 1 35 Rawdon rs. Rawdon II. 133 Setzer rs. Setzer II. 1 34 decisions of Gennan courts regarding II. 1 33. 134 innocently acquired insanity - II. 1 34 laws of Gennan Protestant Church II. 1 34 plea of non-support 11. 1 36 IXSANITY AND LEGITIMACY II. 133 INDEX. 709 PAOE IXSANITY AND LiFE INSURANCE II. 145 cases : Baron von Lindeaau II. 145 Legi-and du SauUe's II. ] 4G Newton vs. Mutual Benefit Lift- Insurance Co II. 147 Insanity and Marriage II. 131 capacity to consent to marriage II. 518 Inspection, medico-legal (see Post-mortem Examination) I. 25 Insurance : accident insurance and benefit associations I. 583 " accident " defined I. 583 beneficial societies I. 587 special statutes regarding them I. 58S death from drowning as an accident I. 586 disease the resiUt of an accident I. 585 injury without visible sign I. 587 negligence I. 587 poison I. 586 " wholly disabled " I. 587 life insurance I. 493 history of I. 493 (fl), legal features I. 498 answers-, incomjjlete and omitted I. 504 superfluous I. 506' beneficiary I. 506 cases I. 507, 50S warranties and representations I. 498 cases I. 499-504- (6) medico-legal relations to I. 509 disease, freedom from I. 523 diseases legally commented on : Bright's I. 537 cold I. 540 consumption I. 529 dyspepsia I. 534 fits I. 534 headaches I. 540 heart disease I. 535 hemoptysis I. 532 insanity TI. 145 of eye I. 539 of liver I. 538 rheumatism I. 536 tonsilitis I. 538 family record I. 554 habits I. 541 medical attendance I. 514 medical examiner I. 510 mortality (see Tables) I. 511 narcotics I. 556 opium liabit I. 551 other insurance I. 562 710 IXDEX. PAGE IxsuRAXCE. Life insTiranee, medieo-legal relations to : prior rejection I. 564 residence I, 560 sound health I. 519 suicide I. 565 (c) obligations of insured and insurer I. 591 causes of death, inquiry into I. 593 expert examination I. 591 relation of medical profession to insui-ance companies I. 591 (d) tables of actual and computed rates of mortality I. 511 of comparative mortality in tuberciilar and heart diseases . . I. 512 of deaths from consumption I. 530 of mortality in different occupations I. 557 of relative mortality of intemperate persons I. 550 INTELLIGENCE, test of II. 20 Intoxication (see Alcoholi-sm, Insanity) II. 205 from fibiin ferment (see Sm-gieal Pi'actiee) .II. 585 Iodine, xjotassium iodide I. 335 Iron, ferric chloride, ferrous sulphate I. 413 Ieregulap. Practitioner, disabilities of I. 602 Irritation, sexual 11. 51 IS0A3IYLA3IINE I. 491 Jasmine, yellow I. 434 Jervine I. 460 Katatonla II. 51 KLEPT03IANIA II. 102 XiAWS (see Courts and Cases). affecting benefit insm-anee companies I. 588 autopsies, laws regulating I. 27 Fi*ench and German systems I. 57 capacity to know right from wi-ong II. 178, 179, 231 charge of Chief -Justice Shaw II. 231 c-riminal liability for siirgieal malpractice 11. 583 criminal, responsibility of , II. 217 defining insanity, unsoundness of mind, noii compos mentis, lucid inter- vals n. 113, 114, 217, 222 Sir John Nieoll's opinion of lucid intervals II. 114 divorce II. 519 English, on medical expert II. 13 on sodomy II. 545 excise, relation of physicians and surgeons to I. 638 expei"t testimony II. 14 Prench, on wills and testamentary capacity II. 266 Oennan, on insanity and divorce II. 133 German Prote.stant Church, on divorce II. 134 indecent assault I. 649 legal procedures against surgeon, in eases of pregnancy, delivery, etc II. 465 in commitment, etc., of in.sane II. 138-142, 147 legal relations of physicians and surgeons to their patients and to one another I. 595 abortion I. 638 INDEX. 711 pa<;k Laws. Legal relations of physicians and surgoous, etc. : agents I. Gil contract and fees L G04 criminal offenses I. g;jO dentist, standing of I. G4:j diploma, proof of I. G37 duty as to contagions diseases I. G.'J.'J examining boards I. 598 excise laws I. 638 fees, contingent I, 615 expert witness I. 614 who is liable for I. 608 gi'ateful patients I. 638 irregular practitioners, disabilities of I. 596 legislative restrictions L 595 libel I. 640 license laws, medical, theory of I. 596 licenses I. 598 malpractice (see Surgical Practice) II. 583 medical societies I. 639 obligation to obey a call I. 606 to record births II. 417 partnerships I. 635 pharmacists, standing of I. 646 practice of medicine, what is proof of I. 602 prescription, ownership of I. 636 professional confidences I. 616 Carlyle Harris case I. 625 registration I. 600 sanctity of the patient's person I. 632 slander I. 640 unprofessional conduct I. 599 waiver I. 626 license laws, medical, theory and constitutionality of I. 596 life insurance I. 498 marriage 11. 517 rape II. 525 Lkau I. 391 Lesbian II. 50 Liability of custodians of the insane II. 147 Libel on physicians and surgeons I. 640 Licenses (see Examiinng Boards) I. 598 Life, accepted period of (see Death) I. 58 Life Insurance (see Insurance) I. 493 Lithotomy II. 629 Liver, diseases of, as affecting insurance I. 538 Lucid Intervals (see Insanity) II. 113, 222 Sir John XicoU's opinion of II. 114 LrsT-MURDER II. 561 Magendie's Solution (see Morphine) I. 440 Malixoering (see Feigned Diseases) II. 392 712 , IXDEX. PAGE Maltreatjiext of t he insane II. 147 Mania (see Insanity) II. 100, 193 acute II. 100 clirouie II. 100, 102 course of II. 102 defined II. 193 recoveries in, percentage of II. 103 removal of inhibitory restraint II. 194 sudden passion and frenzy in II. 194 synij)toms of II. 101 JklAXrSTUPRATIOX II. 545 Marriage, age of consent I. 651 ; II. 517, 525- capacity to consent II. 51S cousinumate II. 518 contracted in cxtroiiis II. 135 definition of II. 517 disqualification from relationship II. 519 effect of disqualifications II. 519 paternity of childi-en II. 519 physical conditions rendering marriage invalid II. 427 impotence and sterility II. 497. 504 in females II. 428-431 in males II. 427 Mastoid Disease II. 612^ Meadow Saffrox I. 430 Mecoxio Acid I. 440 Medical, attendance in insurance cases I. 514 ease of Pi'ice vs. Life Insiu-ance Co • I. 514 compensation I. 614 ; II. 149 examiner in relation to insurance I. 510 attendance I. 514 duties of I. 509 expert (see Expert) II. 13, 148 profession (see Laws. Legal Eelations.of Physicians and Surgeons) I. 595 relations to insurance I. 591 societies I. 639 testimony (see Expert) II. 13. 148 as to cause of death in insxirance cases I. 593 Medico-legal (see Laws) I. 595 aspects of death I. 57 inspection I. 25 relations in insanity II. 19 in life insiu'ance I. 509 Megalomaxia II. 87 Melancholia (see Insanity) II. 98 agitata II. 99 chronic II. 100 ci'imes of II. 193 defined II. 98, 191 delusions in II. 100 depression in II. 191 INDEX. 713 PAGE Melancholia, " desire to hang" II. 192 feigned II. 410 hypochondriacal II. 99 simple II. 98 stuporous II. 99 symptoms of II. 98, 191 uncontrollable impulse in II. 192 Mkmory (see Mind) II. 47 Menopause II. 418, 435 Menstruation II. 418 431 menstrual blood-stains I. 179 Mental Defect and Disease in relation to criminal responsibility (see Re- sponsibility) II. 217 Mental Distress as an element of damage II. 385 eases : Hamilton vs. Third Avenue R. R II. 385 Kennedy vs. Standard Sugar-refining Co II. 386 Mclntyre vs. Giblin II. 385 mere mental distress, eases II. 387 Lynch vs. Knight II. 387 Victoria Railway Commission vs. Coultas II. 388 sense of shame II. 386 Hercury I. 396 Methylguanidine I. 491 Microorganisms in wound diseases (see Surgical Practice) II. 589 Microscope, microscopic appearances of diseased nei'vous tissue in in- sanity II. G9 microscopic appearances of hairs and fibers I. 188 examination of blood-stains I. 167 MiCROSPECTROSCOPE (see Spectroscope) I. 143 Mind (see Insane, etc.) II. 19, 28 apparatus of H. 27 localization of II. 27 apperception of II. 19 concepts II. 28 delusions II. 30 feeling II. 28 hallucinations II. 30 ideation II. 28 illusions II. 34 judgment II. 28 memory, aifections of II. 40 forgetf ulness of substantives and proper names II. 47 loss of II. 47 mental aberration, influence of, upon capacity of the individual II. 112 elements, normal and diseased II. 28 weakness II. 29 relation of intelligence to complexity of nervous system II. 20 sensation II. 28 thinking II, 28 unsoundness of II. 113 volition II. 28 714 ■ INDEX. PAGE Mistaken Identity (see Identity) I. 30, 191 Monk's-hood I. 421 Monomania (see Insanity) II. 86- Moral Insanity (see Insanity) II. 200, 252 defined 11. 20O doctrine of II. 201 moral sense II. 201 Morbid Desires (see Insanity) II. 4f> contrary sexuality, Lesbians, sexual perverts, nymphomania, satyriasis . . II. SO' eating human flesh and fgeees II. 49 fear of poisoning II. 49 Morbid Impulses (see Insanity) II. 180, 191, 242: imperative concepts II. 44 cases of II. 45- Morphine I. 439 habit II. 207 insanity diie to II. 205- Mortality (see Insurance) I. 511 Mummification I. 105 Murder (see Blood-stains, Crime, Death). cases : Billings, gunshot I. 263 Briggs, gunshot I. 262' Budge (Mrs.), knife I. 249, 259, 273, 277 Commonwealth vs. Piper I. 169- Cramer (Jennie), arsenic I. 381 Garfield, post-mortem examination I. 43 Guiteau, murder II. 198 Harris (Carlyle), professional confidences I. 625 Heigham, shooting I. 254 Hughes, stabbing I. 270 Klock, shooting I. 268 McNaughton, murder II. 175, 218 Mallon, shooting I. 271 Maybrick (Mi-s.), poisoning I. 357, 369 Meehanicsville, skull fracture I. 268 O'Shea, cutting I. 251 Pritchard, poisoning I. 343 Ravachol, murder II. 184 Eiddle (Mrs. ), poisoning I. 380 Shattuck, shooting I. 281 Sherman (Mrs. ), poisoning I. 350 Steenbergh, contusions I. 275 Thompson, contusions I. 278 Weston, cutting I. 260 Wharton, poisoning I. 347 Whitechapel, identity of bodies I. 61, 75 Muscular Sense, disturbance of II. 32 Mutism, feigned (see Deaf -mutism) II. 409 Mydaleine I. 492 Mydatoxine .' . I. 492 Mydriatic Alkaloids I. 427' ISDLX. 715 PAOE MVOTO.Ml KS II. 621 Mytilotoxixk I. 492 Narceine I. 440 Narcotics as affecting insurance I. 551 Xarcotixe I. 439 Nasal Ixdex (see Identity) I. Gl Negligence as affecting insurance I. 587 Neurasthenia II. 211 as an excuse for crime I. 21 2 Neurine I. 492 Nicotine, nicotin, nicotia, nicotina, Xicotiaita Tahacum I. 4o7 Nitrous Oxide (see Anaesthetics and Surgical Practice) II. 603 NoN Compos Mentis (see Insanity, medico-legal) II. 113 Nux Vomica I. 447 Nymphomania II. 50 Obligations, of insured and insurer I. 591 of physician and surgeon to obey a call I. 606 Obstetrics (see Birth, Pregnancy, and Surgical Practice) II. 459, 463 Cfesarean section II. 456, 459, 460 Occupation", as affecting insurance I. 556 as a clue to identity I. 73, 197 Oil of Vitriol I. 329 Opium I. 439 habit, as affecting insurance I. 551 as cause of insanity II. 59 Organic Poisons (see Poisons) I. 415 Orpiment I. 387 Oth.ematoma II. 78 Para, parakresol I. 490 Paracentesis abdominis II. 623 Paradoxia sexualis II. 555 Paresthesia sexualis II. 555, 559 Paralysis, feigned II. 397 Paraxoia, monomania, intellectual insanity, pai'tial insanity, primary delu- sional insanity (see Insanity) II. S6, 195 and crime II. 196 cases II. 88-90 Guiteau II. 198 defined II. 195 delusions (^vith) II. 87 of grandeur II. 197 of infidelity II. 197 of persecution II. 87, 196 development of II. 89 feigned II. 413 hallucinations in II. 87 illusions due to II. 35 litigiosa, or querident insanity 11. 88 megalomania II. 87 reformatory II. .'^7 sensorielle Verriicktheit ....>, II. 89 716 IXDEX. PAGE Paraxoia, mouomauia, etc., sjanptoms of II. 86 violeuce in II. 197 Paraphasias II. 268 Paretic Dementia, general paresis, general paralysis, paralytic dementia (see Insanity) II. 110, 202 andcriiie II. 202 apparent lucid intervals in II. 112 convulsions in II. Ill ■dementia in II. Ill ■duration of II. 112 emotional state in II. Ill feigned II. 413 moral weakness in II. Ill periods of remission in II. Ill symptoms of n. 110, 203 delusions of grandeur in II. 110 extravagance in II. Ill gait in II. Ill illusions in II. 35 pupils unequally dilated iu II. Ill silliness in II. 204 speech clumsy in II. Ill tremor in II. 204 Partnership between practitioners I. 635 dissolution of, by reason of insanity II. 144 Passivism and sexual perversion II. 564 Patoammine I. 491 Pellagra I. 480 Penis, retraction of, in droAvniug I. 122 Periodical Insanity, folic cireulaire, alternating insanity (see Insanity) II. 91 Pharmacists, professional standing of I. 646 Phenol, phenyl hydrate I. 469 oxj'phenyl-acetic acid I. 490 Phosphorus I. 336 PiQUERS II. 48 Poison, by illuminating gas I. 97 definition of I. 321 as affecting insurance I. 586 effects of a poison I. 321 true poisons I. 321 fear of (see Insanity) II. 49 narcotic, signs of death in I. 95 Poisons, Inorganic I. S21 alkalies and their salts I. 322 ammonia I. 324 analysis of I. 326 caustic effects of I. 325 cerebral effects of I. 325 chemical analyses of I. 324 fatal doses of I. 323 post-mortem appearances I. 323 L\i)i:x. 717 PAGE Poisons, Inorgaxic. Alkalies and their salts : potash and soda I. 322 symptoms I. 322 time of death I. 323 treatment I. 323 antimony I. 341 antimouiureted hydrogen I. 349 antimony chloride, butter of antimony I. 348 history of I. 341 preparation and properties of I. 342 separation from organic material I. 347 tests I. 346 Wharton ease I. 347 arsenic I. 349 amoiuit necessary to prove poisoning I. 381 amounts of, found in body I. 380 Jennie Cramer case I. 381 Riddle case I. 380 detection after long periods I. 383 distribution in the body I. 378 elimination I. 382 examination of drugs, food, vomit, etc I. 377 Mstory 1. 349 aqua toffana I. 350, 490 Sherman case I. 350 ice-cream poisoning I. 355 metallic arsenic I. 355 modern statistics regarding I. 351 accidental deaths. New York City I. 352 deaths from poisoning and from arsenical poisoning I. 351 occiu-renee in uatm-e I. 352 in the arts I. 353, 388 possibility of distinguishing ante- from post-mortem arsenic I. 385 separation of, from the tissues I. 377 soluble salts, Paris and Schweinfurth greens I. 388 tests : for arsenic in pure solutions I. 373 for arsenic in complex solutions I. 374 for solid arsenic I. 372 arsenic acid, arsenates, arsine, arseniureted hydrogen, sulphides I. 386 arsenic in graveyards I. 353 in wall-papers and other fabrics I. 354, 388 arsenical poisoning I. 361 acute and sub-acute I. 358 appearance of first sjTiiptoms I. 359 arsenic eating I. 368 Maybrick case I. 369 cerebral or narcotic I. 361 chronic cases of I. 362 chronic symptoms after large doses and peculiar lesions I. 365 dangerous and fatal doses I. 367 distiu'banees of sensation and of motion I. 364 718 IXDEX. PAGE. Poisons, Ln-organic. Ai'senieal poisoniug : illustrative cases I- 360 poisoning by external application I. 367 post-mortem appearances of body I. 371 of organs I. 371 prognosis and treatment I. 367 symptoms !• 363- time of death I- 359 treatment and antidotes I- 370 trouble ^th digestion !• 363 ai'senious acid, " Rough on Eats " !• 356 arsenious oxide, white arsenic I- 356 poisonous symptoms !• 357 Maybriek case I- 357, 369 properties of !• 35& copper I. 404 antidotes and treatment I- 407 cooking utensils of I- 404 cupric sulphate I- 406 dangerous and fatal doses I- 407 extraction of, fi'om the tissues 1- 408 oceiu'rence of, in natiu'e I- 404 properties of I- 404 tests I- 407 toxicology !• 404 verdigris !• 40 < halogens and their salts !• 333 bromine I- 334 potassium bromide I- 334 chlorine I- 333 potassic chlorate *• !• 333 symptoms I- 333 iodine !• 335 potassium iodide I- 336 iron !• 413 fen-ic chloride I- 413 effects iipon man I- 413 fatal dose I- 413 post-mortem appearances I- 413 ferrous sulphate, green vitriol I. 413 tests for iron I- 414 lead I- 391 acute poisoniug I- 392 post-mortem appearances I- 393 sjTnptoms I- 393 time of death I- 393 treatment I- 393 cause of death I- 395 chronic poisoning I- 394 blue line on gums I- 394 intestinal pains, colica pictorum I. 394 INDEX. 719 PAGE Poisons, Inorganic. Lead, chronic poisoning : symptoms I. 394 excretion of lead I. 395 liow introduced into system I. 391 location in tissue I. 395 properties as a poison I. 391 separating lead from tissues I. 396 tests I. 395 mercury I. 396 calomel, mereurous chloride I. 400 chloride and bichloride I. 400 fatal dose of I. 401 post-mortem ai)pearances I. 401 time of death I. 401 treatment for I. 401 chronic jioisoning I. 398 corrosive sublimate, mercuric I. 400 effects, physiological and poisonous I. 397 elimination of poison I. 400 external poisoning I. 402 mercurial hysteria I. 399^ other irritant compounds of I. 401 separation from the tissues I. 403 tests for I. 402 mineral acids I. 330 aqua f ortis I. 330 boraeic and boric acid I. 332 chromic acid, chromic anhydi-ide I. 331 potassic dichromate I. 332 hydrochloric acid I. 329 distinction from other acids I. 330 muriatic acid I. 329 nitric acid I. 330^ poisoning by fumes of I. 331 oil of vitriol I. 329 sulphiu'ic acid I. 326 external application I. 328 post-mortem examination I. 328 symptoms I. 327 tests I. 328 treatment I. 327 phosphorus I. 336 dangerous and fatal doses I. 339 poisoning by vapor of I. 339^ necrosis of jav^' from I. 339 vs. atrophy of liver I. 338 post-mortem changes I. 338 properties, physiological I. 336 poisoiious I. 337 symptoms I. 337 tests I. 340 720 IXDEX. PAGE Poisons, Inorganic. Phosphorus : time of death I. 338 treatment and antidotes I. 338 silver I. 411 argentic nitrate I. 412 chronic poisoning by I. 412 tests I. 412 tartar emetic I. 342 chronic cases of poisoning by I. 344 dangerous and fatal doses I. 344 elimination of I. 345 physiological effects, external I. 342 internal I. 343 poisonous effects of I. 343 post-mortem appearances I. 344 Pritchard case I. 343 prognosis I. 344 sjonptoms , I. 343 times of death I. 345 zinc I. 409 chloride I. 409 in canned vegetables I. 41 1 internal administration I. 410 post-mortem appearances I. 411 sulphate, white ■^'itriol I. 409 tests I. 411 Poisons, Organic I. 415 alkaloidal I. 415 aconite and aconitine I. 421 detection of the poison I. 423 in the contents of the stomach I. 423 in the tissues I. 423 fatal quantity I. 422 period when fatal I. 422 post-mortem appearances I. 422 properties I. 421 symptoms I. 421 tests I. 423 treatment I. 422 aeonitin, aconitina, and aconitia I. 421 aconitum f erox I. 421 aeonitum Fischeri I. 421 aconitum Napellus I. 421 monk's-hood I. 421 wolf's-bane I. 421 atropine and belladonna I. 424 atropin, atropia, atropa belladonna, deadly nightshade I. 424 detection of the poison I. 426 in the contents of the stomach I. 426 in the tissues I. 427 fatal cpiantity I. 424 INDEX. 721 PAGB Poisons, OlinANic. Alkaloidal, atropine and belladonna : period when fatal I. 424 post-mortem ai)pearaiiceH I. 425 properties I. 424 symptoms 1 . 424 tests I. 425 physiological I. 425 Vitali's I. 426 Wormley's I. 426 treatment I. 425 brucine (synonyms, Ijrueiu, hnicia) I. 460 symptoms and tests I. 460 cocaine I. 428 cocatannic acid I. 428 detection of tlie poison I. 430 erytliroxylon coca I. 428 fatal quantity I. 429 period when fatal I. 428 post-mortem appearances I. 429 properties I. 428 symptoms I. 428 tests I. 429 ferric cliloride I. 429 odor T. 429 permanganate I. 429 physiological I. 429 treatment I. 429 colchicum and colcliicine (synon^Tns, colcliicin, colchicia, colchicina). . T. 430 active princi^jle of meadow saffron I. 430 detection of the poison I. 432 fatal quantity I. 431 period when fatal I. 430 post-mortem appearances I. 431 properties of the alkaloid I. 430 resistance to putrefaction I. 432 symptoms I. 430 tests I. 431 Mandelin's I. 431 nitric acid I. 431 physiological I. 432 Zeisel's I. 431 treatment I. 431 color-reactions of alkaloids (jilate) I. 415 composition I. 415 conium and coniine (synonyms, eoniin, conine, conia, conicine, and conicina) I. 432 active prineiiile of hemlock I. 432 detection of the poison I. 434 fatal quantity I. 433 pei'iod when fatal I. 433 post-mortem appearances I. 433 722 IXDEX. PAGE Poisons, Oegaxic. Alkaloidal, eonium and coniine : properties of the alkaloid I- 433 symptoms !• 433 tests I- 433 alloxan I- 434 bTityrie acid I- 434 hydroeliloric acid I- 433 odor I- 433 treatment I- 433 gelsemium, gelsemine, and gelsemie acid (synonyms, gelsemin and gelsemia) !• 434 active principle of yellow jasmine I- 434 detection of the poison I- 436 gelsemie acid in the stomach I- 436 gelsemine in the stomach and in the tissues I. 437 fatal quantity I- 435 period when fatal I- 435 post-mortem appearances I- 436 properties of I- 435 gelsemie acid !• 436 gelsemine !• 436 symptoms I- 435 tests for gelsemie acid !• 436 fluorescence • !• 436 nitric acid test I- 436 sulphuric acid and ammonia test I- 436 tests for gelsemin , !• 436 nitric acid test !• 436 oxidation test I- 436 treatment I- 435 hyoseyamus and stramonium I- 427 active principle of datm-a stramonium I- 42 / hyoscyamine, hyoscine, hyoseyamus niger, henbane I- 427 isomer of atropine I- 427 mydriatic alkaloids I- 427 symptoms I- 427 tests I- 428 niix vomica and strychnine (sjTionyms, strychnin, strychnia) I. 447 chemical properties of strychnine I- 44 < detection of the poison I 451 crystals from stomach I- 457 detection after long periods I- 459 in the contents of stomach I- 456 in the tissues I- 458 quantitative determination I- 4;)8 diagnosis I- 449 elimination I- 459 failure to detect I- 459 fatal quantity I- 450 period when fatal !• 450 post-mortem ax>pearances !• 451 INDEX. 723 PACK Poisons, OKfiAXif. Alkaloid, almix voniicii ,iud stiyehnine : seed of strychiios mix- vomica I. 447 symptoms of poisoning by I. 44S tests I. 4r>l color test I. A-^t'l crystals of strychniiic eliromate , I. 45.") physiological test I. 4.')G taste I. 4')! treatment I. 450 opium and morpliinc I. 439 alkaloids contained in opium I. 439 codeine I. 443 meeonie acid I. 440 nareeine I. 440 nareotine I. 439 papaverine I. 440 thebaine I. 440 detection of poison I. 443 in contents of stomach I. 443 in contents of filter for meeonie acid I. 444 in contents of filter for morphine I. 444 in crystals of morphine from stomach I. 44.") in the tissues I. 440 diagnosis I. 441 failure to detect I. 44(5 fatal quantity I. 441 period when fatal I. 441 pharmaceutical preparations I. 440 Magendie's solution I. 440 post-mortem appearances I. 442 properties of morphine I. 440 symptoms ; I. 440 tests for nieconic acid I. 442 ferric chloride I. 443 lead acetate I. 443 tests for morphine I. 442 iodic acid I. 443 ferric chloride I. 442 nitric acid I. 442 sulpho-molybdic acid I. 443 treatment I. 441 symptoms produced in case of poisoning I. 417 detection I. 418 post-mortem appearances I. 418 treatment I. 417 tobacco and nicotine (s.vnonyms, nicotin, nicotia, nicotina) I. 437 active principle of Nicotiana Tahaciim I. 437 detection of the poison I. 439 fatal quantity I. 438 period when fatal I. 438 post-mortem appearances I. 438 724 INDEX. PAGE Poisons, Organic. Alkaloidal, tobacco and nicotine : properties of the alkaloid I. 437 resistance to putrefaction I. 43& symptoms I. 437 tests I. 438 liydi-ocliloric acid I. 438 iodine I. 439 mercuric chloride ' I. 438 physiological I. 439 treatment I. 438 veratmm, verati-ine, and jervine I. 460 active principle of hellebore I. 462 detection of the poison I. 462 in contents of stomach I. 462' in tissues I. 463 fatal dose I. 461 period when fatal I. 46] post-mortem aj)pearances I. 461 properties of the alkaloid I. 461 sjTuptoms of poisoning by I. 461 tests for jervine I. 462 tests for veratrine I. 462 hydi'ochloric acid I. 462 physiological I. 462 suljjhuric acid I. 462 treatment I. 461 not alkaloidal I. 463 camphor I. 472 post-mortem appearances I. 473 symptoms I. 472 treatment I. 473- eantharides or Spanish fly I. 472 detection of poison I. 472 post-mortem appearances I. 472 symptoms I. 472 treatment I. 472 carbolic acid (sjoionyms, phenol, phenyl hydrate) I. 469 detection of poison I. 472 fatal quantity I. 472 period when fatal I. 472 post-mortem appearances I. 472 symptoms I. 470 tests, bromine I. 471 ferric chloride I. 471 hj^jochlorite I. 471 chloral, chloral hydi'ate I. 468 detection of poison I. 469 fatal period I. 469 fatal quantity I. 469 post-moi-tem appearances I. 469 resistance to decomposition I. 469 iM>i:x. no I'.vriK Poisons, Ok<;anic. Not iilkaloidal, diloral, Vliloral liydrate : symptoms I. 4(iH tests I. 4()'J tveatiiifiit I. 4(j!> chlorofoi'in 1 . 4()(> detection t^^ jioisoii I. 4(i>i resistance to dcc<)iii]p()sitii)ii I. 408 («) taken as a li<|ui fatal (jiiaiitity I. 4G(> period wlieii fatal I. 4(50 ])ost-inortciii appearances I. 407 symptoms I. 4t)f> treatment I. 40G {h) taken as a vapor liy the lungs I. 407 fatal period I. 4()7 fatal quantity T. 4()7 post-mortem appearances I. 407 symptoms I. 407 treatment I. 407 tests I. 407 Coccitlits JiKlifiis I. 47iJ detection of the poison I. 473- picrotoxin I. 47;i post-mortem appearances I. 47:i symptoms I. 473 treatment I. 473 croton oil I. 4 71 detection of t he poison I. 471 post-mortem appearances I. 471 symptoms I. 471 treatment I. 471 digitalis, foxglove (synonyms, digitalin, digitonin, digitoxin, digitalein, toxiresin) I. 4t)3 detection of the poison I. 4(i5 fatal quantity. I. 404 period when fatal I. 404 post-mortem appearances I. 404- resistance to putrefaction I. 405 symptoms I. 403 tests : Grandeau's I. 404 Lafon's I. 4(5.> treatment I. 475 Poisons, Ptomaines, and other putrefactive products I. 475 animal alkaloids I. 475 distinctive color-reactions I. 487 poisons formed during putrefaction I. 491 cancroin I. 492 cholin I. 492 ethylendianiin and ethylidendiamin I. 491 fugin I. 492 gadinine I. 492 72G INDEX. PAGE Poisons, Ptomaines, etc. Poisons formed during piitref action : isoamylamine I. 491 methj'lguanidine I. 49 L mydaleine I. 492 mydatoxine I. 492 mytilotoxine I. 492 neiirine I. 492 patoammiue I. 491 ptomo-muscarines I. 492 susotoxine T. 492 tetanine, tetanotoxine, spasmotoxine, and tetanus toxalbumins I. 491 trimethylendiamiu I. 491 typhotoxine I. 492 tyi'otoxicon I. 492 poisons formed in decomposing tissue in tlie presence of arsenic I. 490 acquetta di Perugia I. 490 aqua toffana I. 490 purity of reagents I. 476 putrefactive products I. 487 hydroparacumaric acid (para-oxyplienyl-propionie acid) I. 489 indol, indoxyl (indirubin and indigo-blue) I. 489 parakresol I. 490 para-oxyphenyl-acetic acid I. 490 plienol I. 490 sliatol (methyl indol), skatol-acetic acid I. 489 putrefactive products resembling the vegetable alkaloids I. 477 eolchicine-like products I. 483 delphinine-like products I. 482 staphis agria I. 482 ■digitaline-like products I. 482 experiments on effects of I. 485-487 morphine-like products I. 484 nicotine-like products I. 479 ;stryclinine-like products I. 480 pellagra I. 480 veratrine-like products I. 481 tests for (see under each poison). Poppy, papaverine, papaver somniferum I. 439, 440 PoRPHYRiDiUM, spores of, in microscopical examination of blood-stains I. 170 Post-mortem Examinations I. 25, 57 accepted period of life I- 58 authorities I. 57 autopsies and coroners' inquests I. 27, 57 Iblood (of) I. 37, 43, 88 Islood-stains (of) I. 29 contusions (of) I. 32 ci'iminal assaults I. 33 rape followed by murder I. 29 seminal stains I. 29 decomposition and putrefaction (see Death) I. 35, 99-107 determination of age I. 56, C4, 60 INDEX. Til PAGE Post-mortem Examinations. Determination of age : antlii'opologieal aids to I. 59 as determined by skeleton I. 56, 08 determination of identity (see Death and Identity) I. 30, '.i'l, 59 cases of mistaken identity I. .'5(J Tielibornc claimant I. 71 Whitecliapel murders I. 01, 75 determination of manner of death (see Deatli) I. 20, 58 by asphyxiation ' I. 120 drowning I. 88 electricity I. 134 hanging and strangulation I. 33, 110 poison I. 33, 97 starvation I. 134 suicide I. 32, 88 violence ■ I. 32, 47, 58 finger-marks I, 32 government regulation of I. 27, 57 in France and Germany I. 57 need of reform I. 26 injuries on genitalia I. 33 contusions and lividities I. 32, 35 medico-legal inspections I. 25, 57 importance of I. 26, 57 methods and safeguards I. 26, 95 classification of I. 26 ■order of I. 27, 37 appearances in chloroform narcosis II. 590 bodies advanced in putrefaction I. 53 of children I. 51 examination of abdomen I. 42 bladder I. 48 bones I. 55 brain I. 39, 40 female organs I. 48 signs of abortion II. 475 heart I. 44 kidneys and spleen I. 4S liver I. 50 spinal cord 1. 40 stomach and diiodenum I. 49 thorax I. 42, 43 external examination of body I. 32 contusions, iinger-marks, wounds I. 32, 33 identity of body I. 30 inspection of natural orifices I. 33 corrosive poisons, strangulation, epilepsy, criminal assaults I. 33 internal examination I. 35 instruments, proi)er time for T. 36 is life extinct ? I. 27 position of bodj- I. 29 728 INDEX. PAGF- PosT-JiORTEJi Examinations. Order of : post-mortem lividities, ecchymoses, and decomposition I. 35- smToundiug circumstances and objects I. 28- suspended animation I. 88 temperature of body I. o-l, 90 purpose of I. 25 safeguards to be observed I. 26 tables : of details to be noted I. 75 of hair I. 74 of skeleton I. 64, 68 of teeth I. 67 of weights of organs I. 50 wounds I. o2, 71 edges of I. 33 gunshot, search for bullet I. 47 Garfield case I. 47 inflicted during life I. 33 of the neck I. 32 penetrating I. 32 suicidal I. 32 Potash I. 322 Practice of Medicine, what constitutes proof of I. 602 Prescription, ownership of I. 636 Primary Dementia (see Insanity) II. 1 09 , Professional Confidences of physicians and surgeons I. 616 Carlyle Harris case I. 625 Progeny of the insane (see Insanity and Heredity) II. 58 Psychiatry II. 177 Psychical deafness and blindness II. 268 Ptomo-muscarines I. 492 Puerperal Fever II. 457 Puerperal Insanity (see Insanity) II. 103 Putrefaction (see Death and Post-mortem Examinations) I. 99, 475 Railway Spine II. 307 Rape II. 525 actual and apparent age II. 543 age of consent I. 651 ; II. 525 coitus, anatomical changes induced by, in labia, in h^Tuen II. 527, 528 conditions indicating II. 526 genital discharges II. 537 proof of presence of semen II. 535 state of vaginal wall and mucous membrane II. 535 venereal diseases communicated in II. 536 causes of infection other than sexual contact II. 537 gonon-hea, presence of gonoeoeci II. 536 false accusations of II. 542 for blackmail II. 542 the result of illusions, cases II. 211. .342 followed by murder I. 29 force, moral II . 540 physical evidences of II. 539 ISDKX. 7 -J J pa(;k Rai'K, fraud, intercourse accomplished tlirouj^h II, 540 lej^al coiisideriitioiis II. 525 sec'Oiuliiry eonsequeiiees of II. 544 sexual assault, on children I. fi4!) ; II. 54;i on male children II. 544 states of hypnosis and autohyjjnosis II. 541 non compos mentis 11. 543 unconsciousness, f!icilitatiii<^ II. 540 Raptus Mei.anchulicu.s II. 1 \y.i Realoak I. ;j>i7 Reflex Action (see Insanity) II. 21, 29 Recistratiox of physicians and surgeons I. GOO Relations of medical profession to life insurance I. 514, 591 Religious Excitement (see Insanity) II. 51 Representations in relation to insurance I. 498 Residence in relation to insurance I, 560 Responsibility, Criminal II. 2i;j, 217, 245 apiireciation of nature of acts II. -'.VI case of People rx. Barber II, 2.'j;j criminal-law definitions of II. 217-220 Coke, Hale II. 217 MeXaghteu case II. 218 delusions as a defense for crime ■ II, 230, 234 cases II. 235-241 dementia (accidental) or insanity II. 222 ei)ilepsy II, 223 lucid intervals II, 222 (natural) or idiocy II, 220 cases II. 221 partial insanity II. 224 total insanity II. 222 cases II. 225-231 effects of mental disease upon emotions and will II. 242, 251 cases II. 243-253 ■ evidences of design II. 232 impulse, maniacal II. 250 uncontrollable II. 44. 180, 191, 243 cases II, 245-251 moral insanity II. 252 eases II. 253-258 motive or absence of II. 234 "right or wrong" test IT. 228 Responsibility in Civil Cases II. 1(59 of children II. 1S4 of surgeon for malpractice TI. 573 of tlie insane (see Insanity) II. 1 70 Rheumatism as affecting insurance I. 536 RinoR Mortis (see Death) , I. 93 Rough on Rats I. 3.56 Sadism II. 500 Sanctity of the Person of patients I, 632 730 INDEX. PAGE' Saponification (see Death) I. 105- Satyriasis • 11. 50- Scalds (see Wounds) I. 288 Scalp, atheroma of II. GU9 Selp-Mittilation (see Insaue Impulse) II. 48 Seminal Stains I. 29, 184 ; II. 536- Senile Dementia II. 109 Sensorielle Verrucktheit II. 34 Sepsis, septica?mia I. 90 ; II. 587 Sex, defective sexual organs II. 418, 422' medico-legal importance of diseases of sexual organs II. 425, 426- determination of. II. 418 hermaphrodism II. 418, 419 cases of II. 419-425' gynanders and androgyns II. 419 menopause II. 435' menstruation, normal and abnormal II. 43] puberty and attendant phenomena II. 429 Sexual Impulses (see Insanity) II. 49 Sexual Irritation (see Insanityj '. II. 51 Sexual Perversion II. 48, 550^ anomalies, congenital and acquired II. 552. 554 bestiality II. 547 contrary sexuality II. 569 eases of II. 570 education, influence of, upon II. 554 psychosexual development II. 551 erotic f etichism II. 566- body fetichism, and cases of II. 567 dress fetichism, and cases of II. 568, 569 Lesbians II. 50- lust-min-der II. 561 nymphomania II. 50' passivism II. 564 pederasty II. 546 pathognomonic signs of II. 546 responsibility of perverts II. 545. 572 sadism II. 560 sat jri'iasis II. 50' senile attempt at rape, and cases of II. 551 dementia, abnormal sexuality in II. 1 09 sexual anaesthesia II. 557 hypersesthesia, and cases of II. 557, 558 jDaradoxia II. 555 parfesthesia II . 555, 559 sodomy II. 545 English common law on II. 545 tribadism II. 547 Sexual Vigor, exaggeration of (see Insanity) II. 51 Shock (see Traumatic Neuroses) 11. 297, 303 Silver, argentic nitrate I. 411 ISDEX. 731 I'AfiK SiMiLATiox (^see Feigned Diseases) II. 444 Slandkr of medical injictitioiiers I. G40 Sleep, condition of senn-conscionsness II. 51 dreaming II. ,")! drunkenness II. '>\ rape in II. .■;4i) sorananibulism II. ."il Soda I. :ji2i» Sodomy (see Sexual Perversion) II. .145 SOMN'AJIBILISM II. 51 Spanish Fly I. 472 Spasmotoxine I. 4!H Spectroscope, for deterniining blood-stains I. 142 for determining luvmoglobin I. 1 44 Stokes' band I. 147 Speech Centers II. 24, 269 Speech Disturbaxces II. 270 feigned 11. 410 in aphasia II. 259-296 verbigeration II. 74 Spermatozoa (see Seminal Stains) I. 185 Spontaneous Combustion I. 133 Stains, blood (see Blood-stains) I. 29, 139 seminal (see Seminal Stains) I. 29, 184 Staphis Agria I. 4s2 Starvation, death by I. 134 baby-farming I. ] 37 Welsh fasting girl '. I. 137 Sterility (see Genito-nrinarv Diseases) II. 5(»3 Stokes' Band (see Spectroscope) I. 147 Stramonium, Datura I. 427 Strangulation (see Death and Post-mortem Examinations) I. 33, 116 Strychnine, strychnin, strychnia I. 447 Suffocation (see Death and Post-mortem Examinations) I. liiS-115 and insanity II. 45 and melancholia II. 192 Suicide (see Wounds) I. 280 as affecting insurance I. .565 as aflfecting testamentary capacity II. 128 by carbolic acid I. 88 by drowniing I. 1 28 by hanging or strangulation I. 116 fantastic II. 48 statistics of, in New York for 1891 I. 352 Surgeon, measure of responsibility of II. 57.} partnership liability 11. 5S^ punishment of II. 574, 582 Surgical Practice and Malpractice : accessory wound diseases II. 7t>>9 amputations II. 621 anaesthetics, administration of II. 594 732 ISDEX. PAGE Surgical Practice, etc. Ana?stlietics, administration of: administration of, to pregnant women II. 600 bromide of ethyl (hydro bromie ether) II. 603 cause of death from, direct and indirect II. 595, 596 chloroform idiosyncrasy .II. 598 dangerous or fatal narcosis, treatment of II. 599 defense in II. 604 ■death from II. 594 post-mortem appearances II. 596 effects of, upon kidneys II. 597 ■ether, objections to •. II. 600 failure to produce results II. 602 nitrous oxide II. 603 aseptic and antiseptic treatment II. 590 accidental wounds II. 593 microorganisms II. 589 precautions II. 593 procedure II. 592 common mishaps in, special or regional considerations : abscess, ampu- tation of breast, aneurism, atheroma of scalp, catheterization of Eu- stachian tubes, cleft palate, embolism, empyema, extraction of teeth, gunshot injuries, harelip, hemorrhage, incisions in neck, injuries of head and neck, intoxication from fibrin ferment, lacteal fistula, mas- toid disease, sepsis, tetanus, thyi"oideetomy, tonsilotomy, tracheotomy, traumatic delirium, trephining, tumors II. 584-614 fractures of extremities II. 614 eoutractiu'e and anchylosis II. 621 deformities following II. 614 gangrene following II. 617 hip-joint injuries and disease II. 618, 619 resection II. 620 tenotomies and myotomies II. 621 genito-urinary organs II. 625 abscess of testicle, castration, catheterization, circumcision, extrava- sation of urine, hernia, hydrocele, hysterical atony, lithotomy-, vesical calculus : II. 625-629 improper iutrodiietion of non-professional into case II. 580 malpractice, burden of proof of II. 581 contributory negligence in II. 581 critei'ia of II. 576 defense in II. 581 definition of '. II. 573 errors in diagnosis and of judgment II. 576 experimental surgery 11. 580 gratiutous services II. 578 latest methods and appliances II. 577 liability (criminal), action barred by recovery for services II. 583 common-law provisions II. 583 measure of resjionsibility II. 573 when aseptic principles are violated II. 591 partnersliip liability II. 583 iM>i:.\. 7;;;] I>A(JK Surgical PRAfTiCE, etc. Malpvactico, l>ui(l-•"> procedure not rcslrictcd II. 'liH' response to cull II. "iTT warranty to ciiic II. ;")78 Survivorship I. ii.'M case of Underwood vs. Win<; I. L'3G SU-SOTOXINE I. 492 Suspended Ani.mation I. 88 Symphyseotomy II. 459 Syncope I. 88 Syphilis II. 509 Tables and Statistics : accidental deaths in New York City, 1 870-91 I. 352 antesthetics, mortality from use of II. 379, GOl Baleli, experiments on effects of gunshot wounds I. 254 blood-corpuscles, measurements of I. 173 comparative actual and computed ratea of mortality I. 511 nu>rtality in tubercular and heart diseases I. 512 deaths from arsenical poisoning I. 351 consumption in New York City and in Mutual Life Insurance Co I. 530 poisoning in England and Wales, 1883-87 I. 351 details to be noted in examining into identity I. 75 hair, according to race characteristics I. 19G insanity, classification of, by Hamilton II. 5G Maudsley II. 57 Von Krafft-Ebing II. 55 extent of hallucinations, etc II. 34 symptoms favorable and the reverse II. 64 mortality in diffei-ent occupations I. 557 (relative) of intemperate persons I. 550 railroad accidents II. 307 stature : Orfila's- method I. G^ Sue's method I. G9 suicides in New York City in 1891 I. 352 teeth I. G7 weights of organs of human body I. 50 Tartar Emetic I. 342 Tattooing I. 72, 202 Teeth, extract ion of, mishaps occurring in II. Gil identification by I. 195 post-mortem examination of I. 56, G7 Temperature of body at time of death I. 34 Tenotomies II. 621 Tests for blood I. 157, 1()2 signs of death I. 9b 734 INDEX. PAGE Tests for blood, suspected blood-stains I. 152, 157 aconite, etc I. 423 antimony I. 347 arsenic !• 372, 374 belladonna and atropine with I. 425 Vitali's method I. 426 Wormley's method I. 426 carbolic acid with bromine, ferric chloride, hypochlorite I. 471 chloral !• 469 chloroform I- 469' cocaine with ferric chloride, odor, permanganate, physiological I. 429 colchicum with Mandolin's, nitric acid, physiological, Zeisel's I. 431, 432 coniine with alloxan, butyric acid, hydrochloric acid, odor I. 433, 434 copper I. 407 digitalis with Grandeau's, Lafon's I. 465 gelsemic acid with ammonia, fluorescence, nitric acid, sulphuric acid. . I. 436 gelsemine with nitric acid, oxidation I. 451 iron I. 414 jervine !• 462 lead I. ♦ 395 meconic acid with ferric chloride, lead acetate I. 443 mercury I- 402 nicotine with hydrochloric acid, iodine, mercuric chloride, physiolog- ical I. 438, 439 opium and morphine with ferric chloride, iodic acid, nitric acid, sulpho- molybdic acid I- 442 silver I- 412 strychnine with color, crystals of strychnine chromate, physiological, taste I. 451 veratrine with hydrochloric acid, physiological, sulphuric acid I. 462 zinc I. 409 Testamentary Capacity II- 115 as affected by alcoholism II- 123 delusions II- 118 dementia II- 116 disease II- 120 eccentricity II- 119 epilepsy II. 1 22 hypnotism II- 1 27 old age II- 116, 117 senile dementia II- 116 suicide II- 128 proof of a disposing mind II- 115 German decisions regarding II. 115 what constitutes II- 115 Tetanine, tetanotoxine, spasmotoxine, tetanus toxalbumins I. 491 Tetanus as a mishap in surgical practice II- 585 Thebaine I- 440 Theory (legal) of criminal responsibility II- 217 Thyroidectomy 11- 612 Tobacco I. 437 IMJEX. 7;}0 PAtiE ToNsiLiTis as iiffet'ting insurance I. b'M Torts by tlie insane II. ] 43 Toxic Insanity II. liOo alcoliolism II. 'l^)'^ cases II. 1^(1(5 offenses duo to II. Jii.") physical and psychic sjnnptoms II. 205, 2(iG cocaine habit II. 209 morpliine habit II. 207 offenses due to II. 208 symptoms of II. 207 ToxiKKsiN I. 463 Tkacheotomy II. 612 TuAUMATK' Deliuitm as a niisluip in surgical practice II. 584 Traumatic Insanity (see Insanity) II. 1 05 Traumatic Neuroses II. 297 tetiology JI. 305 age when most liable to II. 305 ataxiagrauT II. 315 bibliography and index II. 352-360 classification of disorders following injury II. 303 concentration of popidation as aft"ectiug II. 306 condition at time of injury II. 306 subsequent to injury II. 307 definitions and sjTionyms II. 297 diagnosis and prognosis II. 333. 334 feigned II. 402 grave traumatic neurosis, and cases of II. 331, 332 history of II. 298 hysteria (traumatic) II. 305, 334 cases of, in a woman cataleptic II. 350 with violent tremor II. 348 pathology of II. 351 prognosis of II. 350 susceptibility in age, race, and sex II. 335 symptoms of II. 336 metliods of examination and diagnosis II. 321. 322 mooted points II. 300 neurastlienia (traumatic) II. 305 pathology of II. 330. 334 previous condition of health II. 306 sex most liable to II. 305 shock and concussion II. 303 statistics of railroad accidents II. 307 symptoms II. 307 neurasthenia (railway spine), spinal irritation, hypochondriacal neu- roses, unusual, special, muscular and motor, sensory, \4sual, hear- ing, laryngeal, vasomotor, pulse, bladder and kidneys II. 307-320 tests II. 322 for nerves and muscles, traiunatic reaction, sensory and visual s\nnp- toms II. 322-32£> 736 INDEX. PAGE Trejxor, feigned -11. 402 Trephining n. 609 Tribadism 11. 547 Trichomonas Vagina I. 185 Trimethtlendiaaiin I. 491 ToioRS in the neck 11. 613 of abdomen and pelvis II. 622 retropharyngeal II. 612 Ttphojiania II. 103 Typhotoxine I. 492 Tykotoxicon I. 492 Uncontrollable Impulse (see Insanity) II. 242 views of the courts in regard to , II. 244 I'ndue Influence II. 125 TTntrofessional Conduct I. 599 I7n.sox:ndn'ess of Mind , II. 113 degi-ee of II. 130 Urethritis II. 505 Tasa Deferentia II. 504 Teratrum, vera trine I. 460 Verbigeration 11. 74 Verdigris I. 407 Yerrucktheit n. 34, 89 Vitriol, green I. 413 oil of I. 329 thi-owing I. 289 white I. 409 Volition n. 28 disturbances of II. 48 suspended 11. 51 Waiver in professional relations of physicians and siu'geons I. 626 Warranties in relation to insiu-ance I. 498 Weapons (see Wounds) ; I. 275 Weight of brain I. 20 Wills (see Testamentary Capacity). French laws regarding II. 266 made in extremis II. 116 of di-unkards ' II. 123 insane II. 170 suicides II. 128 Witnesses, the insane as II. 137 Wolf's-bane I. 421 Wounds (see Blood-stains, Death, and Post-mortem Examinations). affecting special parts I. 296 abdominal walls I. 308 bladder I. 314 chest I. 305 diaphragm I. 308 effusions from violence or disease I. 299 facial I. 303 genitals I. 315 INDEX. 737 PAGE WorxDs. AlVct'tiiig si)eciiil parts: lu-ad I. 29G heart I. :Ji»7 intestines I. 310 involving cavities I. LMS kidneys I. 310 liver ; I. :J09 neck I. 304 spine I. 300 fractures of I. 3(11' injuries to spinal cord I. 302 stomach I. 310 vertebrae, dislocation of I. 301 blood npon weapons I. L'To Steeubergli case I. 275 blood-stains, evidence from I. 274 bullets, sliot, or otlier substances in wounds I. 276 burns and scalds I. 288 as cover for crime I. 287 blisters I. 288 bodies destroyed by fire . I. 289 boiling oil and sugar I. 287 boiling water I. 288 electricity by II. 371 contusions and eechymoses I. 244 concussion I. 287 discolorations I. 247 extravasation I. 298 from sand-bags I. 24.") of abdomen I. 24.^ of head I. 297 on living or dead body I. 245 pseudo-eechymosis I. 24(5 corrosive liquids I. 289 danger of I. 258 defined I. 243 dirt, grass, and similar substances in I. 277 dislocations I. 294 effusion from violence or disease I. 299 evidence of weapons and other articles I. 259 Billings case I. 263 Briggs case I. 262 Budge case I. 249, 259, 273, 277 did person move after I. 295 Fort Edwards case I. 269 from blood-stains I. 272 Hughes case I. 270 Klock case I. 268 Mallon case I. 271 manner in which blood flows I. 273 Mechanicsville case I. 268 738 INDEX. PAGE "Wounds. Evidence of, etc : position of body - I. 294 Weston case I. 260 extravasation of blood from a blow I. 298 fractures I. 290 cause of I. 291 from blows I. 247 of bones of skull I. 293 of ribs I. 292 of spine I. 302 spontaneous I. 291 gunshot (see Bullets) I. 252 experiments by Dr. Baleli I. 254, 257, 266, 267 Heigham case I. 254 loss of lead by ball I- 252 made by shot-guns. I. 253 marks of discharge I. 254 self-inflicted I. 258 incised by cutting instruments I. 247 blood-marks from I. 248 Budge case I. 249, 259, 273, 277 made immediately after death I. 249 signs of healing I. 248 lacerated I. 250 O'Shea case I. 251 position of weapon, clothes, or body I. 277 post-mortem examination of I. 32-47 relation of medical witness I. 315 severity of I. 258 suicide I. 280 Captain Colvocoresses case I. 282 determination between suicid^ and accident I. 284 weapons, blood upon I. 275 Budge case v I- 249, 259, 273, 277 evidence of I. 249 hair upon I. 276 position of I. 277 Thompson case I. 278 where more than one I. 279 Bruin ease I. 281 Shattuck case I. 281 wound diseases, accessory 11. 588 microorganisms IT. 589 Zinc, zinc chloride I. 409 Hl8 2. Co\ . 1 1 ^ <^ 4a \ KH loS-J H »3 2. CO r